THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 
LOS  ANGELES 


IJR.  GEORGE  W.  JEAN,  SJ\NTA  B/iJlBARA,  CAUP, 


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http://www.archive.org/details/eyeasaidingeneraOOIinniala 


THE  EYE 


AS  AN  AID  IN 


GENERAL  DIAGNOSIS. 


A 

HAND-BOOK 
FOR  THE  USE  OF 


Students  and   General   Practitioners. 


BY 


E.  H.  LINNELU  M.  D. 


PHILADELPHIA: 
THE  EDWARDS  &  DOCKER  CO., 

1897. 


Copyright,  1897, 

By  E.  H.  LINNELL. 


Dedicated  to 

J.   E.   IvINNELL,   M:.  E>., 

my  Father,  my  Physician, 

and  my  Friend. 


HIS 

I  Y^7 


\ 


TABLE  OF  CONTENTS. 


Introduction.         -- 7 

PART   FIRST. 

The  Eye  Symptoms  of  Nervous  and  Constitu- 
tional   Diseases. 9 

Chapter  I. 

Affections   of    the    Eyelids,    Conjunctiva,    Orbit, 

Globe,  Sclera  and   Cornea.         -        -        -  11 

Chapter  II. 
Affections  of   the  External  Ocular  Muscles.         -  27 

Chapter  III. 

Affections   of   the    Lens   and    Iris.      Behavior   of 

Pupil  and  of  the  Accommodation.     -         -  54 

Chapter  IV. 

Ophthalmoscopic  Appearances  of  the  Fundus 
Oculi,  Including  Affections  of  the  Choroid, 
Retina  and  Optic  Nerve.  -         -         -         -  80 

Chapter  V. 

The  Sight  and  the  Field  of  Vision.  The  Signi- 
ficance of  Visual  Disorders  Due  to  Le- 
sions Implicating  the  Intra-Cranial  Course 
of  the  Optic  Nerve  Fibres,  Including 
Affections  of  the  Chiasm,  Tract,  the 
Optic  Ganglia  and  the  Cortical  Visual 
Centres  and  Psychic  Visual  Disorders.      -         108 

Chapter  VI. 

A  Tabulated    Statement  of    Diseases   with    More 

or  Less  Characteristic  Eye  Symptoms.      -         127 

PART  SECOND. 

Reflex  Neuroses. 141 

(5) 


6  TABLE  OF  CONTENTS. 

Chapter  VII. 

The  Relation  of  Ocular  Affections  to  Functional 

Nervous  Diseases. 143 

Chapter  VIII. 

The  Relation  of  Affections  of  Remote  Organs  to 

Ocular  Neuroses. 174 

PART  THIRD. 

Ocular  Aflfections  of  Toxic  Origin.      -        -        -         187 

Chapter  IX. 

Toxic  Amblyopia,  Chronic  Retrobulbar  Neuritis  : 

(a)  Tobacco    and    Alcoholic    Amblyopia ; 

(b)  Retrobulbar    Neuritis    Due   to    Other 
Poisons.      - 189 

Chapter  X. 

Ocular  Affections  Caused  by  Various  Therapeu- 
tic Agents :  (a)  Disorders  of  Vision ;  (b) 
Pupillary  Phenomena,  Disturbances  of 
Accommodation  and  Other  Ocular  Symp- 
toms Caused  by  Therapeutic  Agents.         -         200 

Chapter  XI. 

Ocular  Affections  Resulting  from  Poisonous  Sub- 
stances Not  Medicinal,  Administered  Ac- 
cidentally or  by  Design,  or  Connected 
with  Certain  Avocations.  -         -        -        -         214 

Chapter  XII. 

Ocular  Affections  Due  to  Toxic  Substances  Con- 
tained in  Certain  Articles  of  Food  and 
Drink ;  (a)  Fungus  Poisoning ;  (b)  Pto- 
maine Poisoning.  Ocular  Symptoms  At- 
tending  and   Following  Anaesthesia.         -         221 

Bibliography. 227 

Index. 234 


INTRODUCTION. 


pXAMINATION  of   the  eyes  affords  valuable   aid  not 
only    in    the    diagnosis    of   diseases    of    the    central 
nervous  system,  but  also  of  constitutional  affections  and 
diseases  of  other  organs. 

It  has  long  seemed  to  the  writer  that  this  sub- 
ject was  too  much  neglected  by  the  general  practitioner. 
The  record  of  the  pulse,  temperature  and  respiration,  uri- 
nary analysis,  etc.,  are  among  the  every  day  routine  meth- 
ods of  diagnosis,  but  the  indications  furnished  by  the 
eye    are  too   little  understood,  and  too  often  overlooked. 

When  this  treatise  was  commenced,  it  was  with 
the  conviction  that  such  a  work  was  demanded,  as 
there  was  then  no  similar  treatise  in  the  English  lan- 
guage. Much  of  it  was  completed  before  the  appear- 
ance of  the  encyclopaedic  work  of  Knies  entitled  "  Re- 
lations of  Diseases  of  the  Eye  to  General  Diseases,"  and 
I  have  freely  availed  myself  of  any  information  con- 
tained therein,  which  had  not  previously  come  to  my 
knowledge. 

It  has  not  been  my  purpose  to  enumerate  all  the 
eye  symptoms  which  may  be  associated  with  the  various 
constitutional  and  local  diseases,  but  rather  to  emphasize 
such  as  are  of  direct  importance  in  the  way  of  diagno- 
sis, and  to  present  such  data  so  as  to  be  of  ready  refer- 
ence and  practical  value. 

(7) 


8  INTRODUCTION. 

The  book  has  been  written  from  the  standpoint 
of  the  specialist  for  the  student  and  general  practitioner. 
It  embodies  the  personal  experience  of  the  writer  dur- 
ing a  general  practice  of  twenty  years,  and  fifteen 
years  experience  in  the  treatment  of  ocular  diseases,  in 
addition  to  extensive  reading. 

I  have  not  endeavored  to  go  into  the  symptoma- 
tology or  differential  diagnosis  of  the  various  ocular  af- 
fections which  are  discussed,  further  than  the  purpose  of 
the  work  demanded,  or  into  the  treatment  of  such  affec- 
tions. To  do  otherwise,  would  be  to  write  a  treatise 
upon  Ophthalmology.  The  book  is  simply  what  its 
title  indicates,  namely,  a  Handbook  of  Diagnosis,  and 
as  such  I  hope  it  may  find  a  place  among  the  reference 
volumes  of  the  student  and  the  busy  family  physician 
who   aims    to  keep  abreast  of  the  times. 

E.   H.   LiNNELL,  M.   D. 
Norwich,  Connecticut,  April,  1897. 


PART  FIRST. 


THE   EYE  SYMPTOMS  OF   NERVOUS 

AND 

CONSTITUTIONAL  DISEASES. 


CHAPTER  I. 

AFFECTIONS   OF   THE   EYELIDS,    CONJUNCTIVA,    ORBIT, 
EYE-BALIvS,   SCLERA,    AND  CORNEA. 

EYE   LIDS. 

In  examining  the  lids  for  indications  of  general 
disease,  it  is  important  to  notice  the  color  of  the  skin, 
the  presence  or  absence  of  thickening  or  oedema,  of 
inflammation  of  the  ciliary  margins,  of  neoplasms,  the 
movements  of  the  lids,  the  existence  of  dilatation  or 
contraction  of  the  palpebral  fissure. 

More  or  less  anaesthesia  of  the  skin  of  the  lids, 
with  false  localization  of  sensation  is  a  symptom  of 
locomotor  ataxia. 

A  pigmentation  of  the  skin  of  the  lids  accompa- 
nies Addison's  disease  of  the  supra-renal  capsules.  In 
other  cases  it  is  symptomatic  of  uterine  or  hepatic  dis- 
ease. It  is  sometimes  associated  with  abdominal  growths. 
Blue  rings  around  the  eyes  may  accompany  menstrua- 
tion in  debilitated  individuals.  When  they  disappear 
with  the  cessation  of  the  menstrual  flow,  the  symptom 
is  of  no  special  importance,  and  does  not  indicate 
organic  disease. 

A  swollen  oedematous  non-inflammatory  condition 
is  indicative  of  nephritis  and  should  lead  one  to  examine 

1  (11) 


12  THE   EYE   AS   AN   AID   IN   GENEBAL   DIAGNOSIS, 

the  urine,  even  in  the  absence  of  anaemia,  debility  and 
other  concomitants  of  renal  aflfections.  It  is  also  present 
in  general  hydraemia  and  in  heart  disease.  It  accom- 
panies suppuration  within  the  orbit,  but  in  the  latter 
condition,  it  is  sharply  circumscribed  by  the  bony  edge, 
and  this  circumstance  will  at  once  distinguish  this  form 
of  oedema,  from  that  accompanying  the  affections  pre- 
viously mentioned,  in  which  it  is  not  distinctly  circum- 
scribed, but  gradually  merges  into  the  healthy  skin  of 
the  eye-brow  or  the  cheek. 

Oedema  of  the  lids  is  also  suggestive  of  trichi- 
nosis. It  frequently  accompanies  that  disease,  and  may 
be  one  of  its  very  early  manifestations. 

Thickening  and  swelling  of  the  lids  may  be  an 
initial  manifestation  of  myxcedema. 

Eczema  of  the  skin  of  the  eyelids,  especially  of 
the  ciliary  border,  is  frequently  dependent  upon  a  scrofu- 
lous diathesis,  but  in  many  cases  it  is  caused  by  eye 
strain  due  to  refractive  errors,  and  is  cured  by  the  pre- 
scription of  suitable  glasses.  When  neither  of  the  above 
causes  exists,  the  presence  of  an  obstinate  eczema  of 
the  margins  of  the  lids  should  lead  to  an  examination 
of  the  urine,  for  this  is  a  not  infrequent  accompaniment 
of  diabetes. 

Styes,  it  is  well-known,  are  frequently  associated 
with  disorders  of  digestion,  and  with  menstrual  irregu- 
larities, but  they  are  often,  also,  the  result  of  eye  strain, 
and  are  cured  by  correcting  errors  of  refraction.     I  have 


EYE    LIDS.  13 

a  patient  who  had  a  succession  of  styes  for  many 
months.  She  was  not  conscious  of  any  imperfection  of 
her  vision,  but  a  weak  cylindrical  glass  before  each  eye 
cured  the  styes,  and  also  a  headache  from  which  she 
had  frequently  suffered. 

A  tubercular  nodule  sometimes  develops  in  the 
tissue  of  the  eyelid,  simulating  a  large  inflamed  chala- 
zion (a  retention  cyst  of  the  Meibomian  gland).  A 
knowledge  of  this  fact  may  be  of  advantage  in  treat- 
ment. 

It  should  also  be  remembered  that  the  initial  le- 
sion of  leprosy  may  develop  in  the  lid  in  the  form  of 
nodules,  which  are  hard  and  insensitive,  of  a  whitish  or 
pale  yellow  or  reddish  color,  accompanied  with  more  or 
less  infiltration  of  the  sub-cutaneous  tissue.  Anaesthetic, 
whitish  patches  may  also  appear. 

In  studying  the  muscular  conditions  of  the  lids, 
both  paralytic  and  spasmodic  conditions  are  of  diagnos- 
tic importance.  I  will  consider  these  conditions  sep- 
arately as  affecting  the  orbicularis  and  the  levator  of 
the  upper  lid. 

General  debility,  especially  in  old  age,  frequently 
produces  a  laxity  of  the  skin  of  the  eyelids,  with  a  de- 
ficient innervation  of  the  orbicularis,  causing,  second- 
arily, eversion  of  the  eyelids,  and  epiphora  from  malpo- 
sition of  the  puncta,  and  a  chronic  conjunctivitis.  Hence 
such  conditions  suggest  a  lowered  vitality  and  a  need 
for  constitutional  treatment,  and  careful  diet  to  promote 
nutrition. 


14  THE   EYE   AS   AN   AID   IN  GENERAL  DIAGNOSIS. 

A  true  paralysis  of  the  orbicularis  produces  the 
condition  known  as  lagophthalmus,  in  which  the  patient 
is  unable  to  close  the  eyes.  It  is  associated  with  pa- 
ralysis of  the  muscles  of  the  face,  owing  to  their  com- 
mon innervation  by  the  facial  nerve,  and  indicates  the 
peripheral  nature  of  such  a  paralysis,  for  in  90  per  cent 
of  facial  paralyses  of  central  origin  the  orbicularis  and 
frontalis  muscles  escape.  An  explanation  of  such  ex- 
emption is  found  in  the  assumption  that  the  fibres  of 
the  nerve  which  supply  these  muscles  arise  from  a  sep- 
arate nucleus  from  that  of  the  rest  pf  the  nerve.  The 
possibility  of  ear  disease  and  of  syphilis  should  be  borne 
in  mind.  A  paresis  of  the  orbicularis,  causing  imperfect 
closure  of  the  lids,  sometimes  occurs  in  posterior  spinal 
sclerosis — locomotor  ataxia — and  should  awaken  suspi- 
cion of  this  disease.  Sometimes,  in  very  ill  persons,  a 
paralysis  of  the  eyelids  is  simulated  by  a  lack  of  sensi- 
bility of  the  cornea  and  conjunctiva,  so  that  the  natu- 
ral stimulus  to  close  the  eyes  is  lost. 

Diminished  frequency  of  winking  from  the  same 
cause  also  occurs  in  Basedow's  disease,  or  exophthalmic 
goitre,  and  is  known  as  Stallwag's  sign,  or  Dalrymple's 
symptom. 

A  spasmodic  action  of  the  levator  of  the  upper 
lid  (Abadie's  sig^)  is  another  of  the  symptoms  of 
Basedow's  disease,  and  Von  Graefe  first  called  atten- 
tion to  another  characteristic  feature  of  the  affection, 
viz. :   a  spasm  of  Mueller's   muscle.     This  consists  of  a 


EYE    LIDS.  15 

few  unstriped  muscular  fibres  in  the  cellular  tissue  of 
the  orbit,  innervated  by  the  sympathetic.  Its  contrac- 
tion causes  a  widening  of  the  palpebral  fissure,  and  in- 
terferes with  the  associated  movements  of  the  eyeball 
and  the  lid.  This  is  noticed  in  looking  downward,  when 
the  lid  lags  behind,  so  that  a  white  stripe  of  exposed 
sclera  is  seen  between  the  edge  of  the  cornea  and  the 
lid.  This  is  a  characteristic  symptom  of  exophthalmic 
goitre,  and,  together  with  Stelwag's  sign,  gives  the  pe- 
culiar staring  expression  to  such  patients,  and  renders 
the  exophthalmus  more  noticeable.  Starkey  found  Von 
Graefe's  sign  present  in  all  but  12  of  613  cases  of  ex- 
ophthalmic goitre.  It  is  an  early  symptom,  and  may, 
for  a  considerable  time,  be  the  only  feature  of  the  case. 
It  may  affect  only  one  eye,  or  may  be  more  marked  on 
one  side.  In  testing  for  this  sign  it  is  best  to  have 
the  patient  lying  upon  his  back.  His  gaze  should  be 
directed  at  some  object,  first  held  directly  above  his  face, 
then  slowly  moved  downward  toward  his  chest,  when  the 
deficient  movement  of  the  upper   lid   becomes   apparent. 

The  opposite  condition,  that  of  narrowing  of  the 
palpebral  fissure,  was  described  by  Jackson  as  a  symp- 
tom of  posterior  spinal  sclerosis,  and  is  caused  also  by 
an  opposite  lesion,  viz.  :  a  paralysis  instead  of  an  irrita- 
tion of  the  sympathetic.  It  is  sometimes  designated  a 
"sympathetic  ptosis." 

A  tremulous  action  of  the  lids  accompanies  pa- 
ralysis agitans. 


16  THE   EYE   AS   AN   AID   IN  GENERAL   DIAGNOSIS. 

A  spasm  of  the  orbicularis  is,  in  the  majority  of 
cases,  an  expression  of  photophobia.  The  lids  are 
closed  to  shut  out  the  light  which  is  painful,  owing  to 
inflammation  or  hyperaesthesia.  When  no  inflammation 
exists,  a  cause  of  the  hyperaesthesia  and  its  resultant 
spasm  may  sometimes  be  found  in  eye  strain  from  re- 
fractive or  muscular  anomalies,  especially  the  former. 
It  may  also  result  as  a  reflex  neurosis  dependent  upon  a 
a  sexual  or  intestinal  irritation. 

Spasmodic  winking,  or  nictitation  of  the  lids,  is 
also  a  nervous  manifestation,  which  likewise  may  result 
from  errors  of  refraction,  may  accompany  or  precede 
general  chorea  or,  by  reflex  action,  may  be  associated 
with  disorders  of  the  nose,  teeth,  or  digestive  organs. 

We  distinguish  various  forms  of  ptosis  or  inabil- 
ity to  raise  the  lids.  There  is  a  congenital  form,  us- 
ually associated  with  diminished  power  of  raising  the 
globe,  and  supposed  to  be  due  to  a  "  congenital,  central 
defect."  In  other  cases  there  is  a  lack  of  development 
of  the  levator  muscle.  The  writer  is  acquainted  with  a 
Swedish  family  where  all  the  children  exhibit  this  pe- 
culiarity. In  such  cases  there  is  an  overaction  of  the 
frontalis  muscle  which  gives  the  individual  a  peculiar 
anxious  expression.  There  is  a  form  designated  as 
"morning^ ptosis,"  which  occurs  after  sleep  in  debilita- 
ted individuals.  The  levator  is  relaxed  during  sleep, 
and  in  these  cases  a  few  minutes  are  requisite  to  enable 
the  person  to  recover  the  voluntary  contraction  of  the 
muscle. 


EYE   LIDS.  17 

There  is,  also,  an  hysterical  ptosis.  The  latter 
may  be  unilateral  or  bilateral,  and  is  associated  with 
spasm  of  the  orbicularis,  which  latter  is  particularly 
marked  when  the  patient  is  told  to  look  upward.  A 
transient  ptosis  has  been  known  to  accompany  an  irrita- 
tion of  the  fifth  nerve,  from  the  extraction  of  a  tooth. 

These  various  forms  of  ptosis  are  to  be  distin- 
guished from  true  paralysis  of  the  levator  muscle.  The 
latter  may  result  either  from  a  peripheral  neuritis,  such 
as  occasionally  occurs  after  exposure  to  cold,  and  from 
alcoholism,  or  from  a  lesion  of  the  third  nerve  any- 
where in  its  course  from  its  nucleus  of  origin  to  the 
orbit.  An  isolated  paralysis  of  the  third  nerve  is  us- 
ually of  nuclear  origin,  but  it  may  be  caused  also  by 
a  circumscribed  lesion  of  the  cortex  of  the  frontal  lobe 
of  the  cerebrum,  just  in  front  of  the  fissure  of  Rolando. 
The  fibres  of  the  third  nerve  decussate  in  their  intra- 
cerebral course,  so  that  destruction  of  this  centre  causes 
ptosis  of  the  opposite  side.  The  cortical  centres  for  the 
motor  nerves  of  the  eyeball  are  at  a  considerable  dis- 
tance from  this  point,  and  hence  it  is  not  strange  that 
ptosis  sometimes  occurs  as  an  isolated  paralysis,  and 
such  an  occurrence  is  a  valuable  point  in  the  location 
of  cerebral  symptoms  having  this  association. 

Ptosis  is  sometimes  an  accompaniment  of  paraly- 
sis agitans  and  not  infrequently  is  present  in  tabes,  so 
that  its  association  with   these  affections  needs  no  other 

explanation. 
2 


18  THE   EYE   AS  AN   AID   IN   GENERAL   DIAGNOSIS. 

The  significance  of  ptosis  when  occurring  with 
loss  of  function  of  the  other  motor  nerves  of  the  eye- 
ball, does  not  need  separate  discussion  here.  It  is  hardly- 
necessary  to  mention  the  simulated  ptosis  due  to  cica- 
trices caused  by  erysipelas,  or  to  cellulitis  orbitae,  peri- 
ostitis, and  adhesions  between  the  lid  and  eyeball.  Such 
a  condition  could  hardly  deceive  the  most  careless  and 
superficial  observer. 

CONJUNCTIVAL   AFFECTIONS. 

In  considering  affections  of  the  conjunctiva  as  af- 
fording suggestive  hints  in  general  diagnosis,  both  that 
of  the  lids  and  of  the  eyeball  is  understood. 

It  is  desirable  to  note  especially  the  presence  of 
inflammation,  swelling  general  and  circumscribed,  and 
of  new  growths. 

The  various  forms  of  conjunctivitis,  both  palpe- 
bral and  ocular,  are  frequently  idiopathic,  from  exposure 
to  cold,  dust,  strong  light,  etc.,  but  very  often  they  are 
an  indication  of  a  scrofulous  diathesis,  or  of  indigestion, 
and  many  cases  only  yield  to  treatment  after  careful 
prescription  of  glasses.  Conjunctivitis  also  is  frequently 
dependent  upon  nasal  catarrh.  Hence,  when  it  does  not 
readily  yield  to  suitable  treatment,  it  will  often  be  of 
advantage  to  carefully  examine  the  nose  for  the  excit- 
ing cause. 

The  phlyctenular  form,  characterized  by  the  for- 
mation of  small  vesicles  and  pustules,  is  very  frequently 


CONJUNCTIVAL   AFFECTIONS.  19 

caused  by  nasal  disease.  These  phlyctaenae  develop  very 
frequently  along  the  margin  of  the  cornea,  or  some- 
times on  the  cornea  itself.  Knies  says  nearly  90  per 
cent,  of  such  cases  in  children  are  from  such  a  cause. 

It  is  hardly  necessary  for  me  to  mention  the  ob- 
vious causal  relations  of  severe  purulent  conjunctivitis, 
and  the  poison  of  gonorrhoea,  or  other  infectious  secre- 
tions. I  have  known  an  eye  to  be  lost  from  panoph- 
thalmitis resulting  from  infection  with  pus  from  an  ul- 
cerated  tooth. 

Conjunctival  catarrh,  as  is  well-known,  accompan- 
ies the  prodromal  stage  of  measles,  and  it  is  a  frequent 
manifestation  in  the  early  stage  of  epidemic  cerebro- 
spinal meningitis. 

It  is  important  to  recognize  the  diphtheritic  and 
croupous  forms  of  conjunctivitis.  In  both  we  have  the 
development  of  a  pseudo-membrane,  and  the  same  dis- 
tinction is  to  be  made  here,  as  in  the  throat,  in  the  dif- 
ferential diagnosis  of  the  two  affections.  In  the  latter 
the  membrane  is  superficial  and  can  be  removed,  leav- 
ing a  raw,  bleeding  surface,  while  in  the  former  it  is  in- 
terstitial, infiltrating  the  whole  thickness  of  the  mucous- 
membrane  which  is  pale  and  bloodless,  owing  to  ob- 
struction of  the  circulation  by  the  pressure  of  the 
exudate.  A  microscopic  examination  would  be  decisive. 
In  diphtheria  of  the  conjunctiva,  the  constitutional 
symptoms  are  often  severe,  and  the  swelling  and  indura- 
tion of  the  whole  lid  is  much  more  extensive  and  firmer 
than  in  conjunctival  croup. 


20  THE   EYE   AS   AN    AID   IN   GENERAL   DIAGNOSIS. 

Spontaneous  conjunctival  hemorrhages  are  indica- 
tive of  an  atheromatous  condition  of  the  arteries,  and, 
especially  in  elderly  people,  should  lead  us  to  appreciate 
the  danger  of  cerebral  hemorrhage,  and  to  adopt  precau- 
tionary measures.  , 

Such  hemorrhages  are  not  infrequent  in  diabetes, 
owing  to  the  vascular  degeneration  which  occurs  in  that 
disease.  Hemorrhage  into  the  conjunctiva  has  been  ob- 
served in  persons  suffering  with  cholera,  and  is  consid- 
ered of  serious  import. 

Oedema  of  the  conjunctiva. — A  uniform  swelling 
of  various  degrees  of  tension,  with  or  without  inflamma- 
tion, frequently  accompanies  meningitis.  The  exudation 
may  reach  the  orbit  through  the  optic  foramen,  or  it 
may  produce  a  venous  stasis  and  subsequent  exudation 
by  pressure  upon  the  ophthalmic  vein.  It  is  an  import- 
ant indication  of  exudation  in  the  cranial  cavity.  It  is 
frequently  an  early  manifestation  in  both  the  epidemic 
cerebro-spinal   form,  and  in  purulent  basilar   meningitis. 

When  there  is  an  abrasion  of  the  conjunctiva  it 
may  become  inoculated  with  the  bacilli  of  tuberculosis. 
This  may  occur  through  infection  from  the  nose,  skin 
(lupus  is  now  classed  as  a  tuberculous  affection),  or 
lungs ;  or  the  initial  affection  may  be  thus  caused  in  a 
healthy  individual  exposed  to  infection.  It  then  be- 
comes important  to  recognize  it,  so  that  prompt  destruc- 
tion of  the  nodule  may  prevent  constitutional  infection. 
An   ulcer   develops   at  the   point  of    inoculation,  with  a 


ORBIT-EYEBALL.  21 

hard  base  often  covered  with  granulations.  Yellowish- 
red  nodules  develop  in  the  vicinity,  giving  a  granular 
appearance  somewhat  similar  to  trachoma,  within  which 
the  microscope  reveals  the  tubercle  bacilli.  Later  the 
lymphatic  glands  of  the  face  and  neck  become  involved. 
According  to  Eklund,  leprosy  may  also  originate 
in  the  conjunctiva  through  the  use  of  towels,  etc.  In 
view  of  the  increasing  prevalence  of  that  disease  in  this, 
country,  a  knowledge  of  the  fact  may  possibly  be  of 
service.  It  is  said  to  be  caused  by  a  micro-organism 
similar  in  appearance  to  that  of  tuberculosis.  The  pri- 
mary nodules,  pale,  yellowish  or  reddish,  insensitive  and 
hard,  increase  in  size  and  invade  the  other  structures  of 
the  eye. 

ORBIT. 

A  periostitis  or  caries  of  the  orbit,  when  not  trau- 
matic, should  awaken  suspicion  of  either  tuberculosis  or 
syphilis,  as  it  is  usually  caused  by  one  or  the  other. 
Michael  says  that  "  many  cases  of  spontaneous  cellulitis 
orbitae  in  children  and  young  people  may  be  attributed 
to  a  tuberculous  infection  of  the  cellular  tissue." 

EYEBALL. 

The  general  expression  of  the  eye  will  rarely  es- 
cape notice.  The  bright,  lustrous,  staring  eye  in  febrile 
conditions  and  in  mental  excitement  is  familiar  to  all. 
So,  also,  is  the  dull,  expressionless  stare  of  mental  hebe- 


22  THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

tude  or  actual  dementia,  and,  less  markedly,  of  typhoid 
conditions,  et  cetera. 

A  protrusion  of  the  eyeball,  exophthalmus,  is  one 
of  the  cardinal  symptoms  of  Basedow's  disease.  It  is 
usually  bilateral,  but  not  invariably,  or  it  may  be  of 
unequal  extent  in  the  two  eyes.  It  may  be  due  to  or- 
bital growths,  to  suppuration  within  the  orbit,  or  to 
aneurism  of  an  orbital  artery  or  of  the  internal  carotid. 
In  the  latter  case  the  pulsation  of  the  aneurism  will  be 
communicated  to  the  eye,  and  be  perceptible  to  the  ex- 
aminer's fingers.  Sometimes  also  a  bruit  can  be  detected 
by  the  aid  of  the  stethoscope.  Pressure  on  the  cavern- 
ous sinus  or  the  ophthalmic  vein  may  cause  sufficient 
venous  stasis  to  produce  protrusion  of  the  eye,  in  which 
case  the  eye  can  be  readily  replaced  by  gentle  pres- 
sure. An  exophthalmus  developed  in  a  patient  of  the 
writer  after  using  atropin  for  the  examination  of  re- 
refraction,  and  subsided  under  application  of  gentle  pres- 
sure. Exophthalmus  in  the  new-bom  is  sometimes 
caused  by  retro-ocular  hemorrhage.  Such  a  case  came 
under  my  observation.  The  child  was  seen  the  day 
after  its  birth,  and  presented  a  marked  proptosis,  which 
disappeared  in  a  few  days  under  gentle  pressure,  and 
treatment  prescribed  for  a  co-existent  conjunctivitis. 

Every  tissue  of  the  eye  at  times  affords  points  of 
diagnostic  importance.  After  a  brief  consideration  of 
the  sclera  and  cornea  I  will  discuss  disorders  of  motil- 
ity at  some  length,  inasmuch  as  spasmodic  and  paralytic 


CORNEA.  23 

affections  of    the  ocular  muscles  are  of    extreme  import- 
ance in  cerebral  localization. 

The  icteroid  coloration  of  the  sclera  is  too  well 
recognized  to  need  comment,  but  when  occurring  inde- 
pendently of  hepatic  affections,  it  is  suggestive  of  Addi- 
son's disease  of  the  supra-renal  capsules.  Idiopathic 
scleritis  is  a  rare  affection.  Rheumatism  and  syphilis 
are  the  most  frequent  causes  of  inflammation  of  the 
sclera  and  of  the  episcleral  tissue.  Syphilitic  gummata 
may  develop  primarily  in  the  sclera,  but  they  usually 
invade  this  tissue  from  the  uvea.  A  knowledge  of  the 
cause  of  such  affections  will  suggest  a  suitable  line  of 
treatment.  Tuberculous  nodules  also  occasionally  occur 
in  the  sclera.  In  doubtful  cases  the  sclerotic  may  at 
times  afford  conclusive  evidence  of  death  by  the  exist- 
ence of  a  desiccated  patch  within  the  palpebral  fissure, 
either  at  the  inner  or  outer   side  and   below  the  cornea. 

CORNEA. 

The  cornea  reveals  a  constitutional  dyscrasia  very 
readily.  The  occurrence  of  phlyctaenulae  at  the  edges 
of  the  cornea  in  scrofulous  children  has  been  already 
alluded  to  in  speaking  of  conjunctivitis.  Ulcers  and  ab- 
scesses of  the  cornea  are  also  frequently  seen  in  stru- 
mous subjects. 

A  parenchymatous  inflammation  of  the  cornea, 
characterized  by  a  diffuse  infiltration  into  the  deeper 
layers  of  the  membrane,  giving  an  appearance  of  ground 


24  THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

glass,  which  might  be  mistaken  for  a  cataract  by  a 
careless  or  inexperienced  observer,  is  very  characteristic 
of  inherited  syphilis.  It  is  rare  in  the  acquired  form 
of  the  disease.  It  most  frequently  appears  between  the 
sixth  and  fourteenth  years.  Mauthner  estimates  that 
^  of  the  cases  of  interstitial  keratitis  are  syphilitic.  It 
may  accompany  infectious  diseases,  and  it  has  been 
ascribed  to  rheumatism.  Where  corneal  affections  de- 
velop in  children  who  are  free  from  scrofulous  or  syphi- 
litic taint,  the  teeth  should  be  examined,  as  there  seems 
sometimes  to  be  a  relation  of  cause  and  effect  between 
dental' caries  and  such  aflfections.  Tuberculous  nodules 
may  develop  primarily  in  the  marginal  zone  of  the  cor- 
nea, and  later  in  the  cornea  itself.  Ulceration  of  the 
cornea  is  not  of  infrequent  occurrence  in  diabetes,  and 
is  an  indication  of  debility,  and  it  should  be  remem- 
bered that  slight  injuries  in  elderly  and  feeble  individu- 
als, which  readily  heal  in  persons  in  good  health,  are 
very  apt  to  break  down  into  necrotic  suppurative  pro- 
cesses, and  hence  demand  especial  care. 

In  anaesthesia  of  the  trigeminus,  accompanying 
facial  paralysis,  or  in  conditions  of  profound  depression, 
as  in  cholera,  typhoid,  etc.,  a  condition  known  as  neuro- 
paralytic keratitis  develops.  An  ulceration  occurs  which 
spreads  rapidly  and  leads  to  destruction  of  the  mem- 
brane and  irreparable  blindness.  This  is  due  to  injury 
to  the  cornea,  in  consequence  of  its  lack  of  sensibility. 
Because  of  this  lack  of  sensibility,  particles  of  dust,  etc., 


CORNEA.  25 

are  not  felt,  and  the  cornea  is  not  protected  and  kept 
moist  by  the  natural  frequent  closure  of  the  lids.  The 
occurrence  of  such  cases  gave  rise  to  the  theory  that 
there  existed  special  trophic  fibres  in  the  trigeminus 
which  presided  over  the  nutrition  of  the  cornea,  but 
this  was  disproved  when  Snellen  demonstrated  that  sim- 
ple protection  of  the  eye  was  all  that  was  necessary  to 
prevent  such  traumatic  and  infectious  ulcerations.  This 
condition  is  somewhat  analagous,  but  is  to  be  differenti- 
ated from,  the  excessive  dryness  and  loss  of  transparency 
of  the  cornea  known  as  xerosis  or  desiccative  keratitis, 
which  occurs  after  excessive  loss  of  fluids,  as  in  cholera, 
childbed,  etc. 

Anaesthesia  of  the  cornea  occurs  in  locomotor 
ataxia,  so  that  in  some  instances  the  membrane  may  be 
touched  without  producing  winking  of  the  eyelids. 
Sometimes  also  there  is  a  false  localization  of  sensation, 
so  that  a  touch  upon  the  cornea  is  referred  to  the  ex- 
ternal or  internal  canthus. 

A  malarial  cachexia  may  manifest  itself  by  an 
inflammation  of  the  cornea.  Noyes  says,  in  an  editorial 
note  in  Knies '  "  The  Eye  in  General  Diseases  :  " 

"  Keratitis,  as  the  result  of  malaria,  is  not  infre- 
quent, and  presents  features  which  are  more  or  less 
typical.  It  attacks,  by  preference,  the  epithelium  and 
superficial  layers,  is  non-suppurative ;  ulcerations  are 
superficial.  It  is  chronic  in  duration.  There  is  often 
anaesthesia  of    the   surface.     The   opacity  is   apt   to  run 


26  THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

in  streaks,  yet  may  present  itself  in  patches.  One  will 
find  marked  tenderness  of  the  supra-orbital  nerves  as 
they  pass  out  of  the  orbit,  which  is  the  most  valuable 
pathognomonic  sign,  and  when  occurring  with  the  con- 
ditions described,  indicates  the  absolute  necessity  of  qui- 
nine in  eflfective  doses  as  an  adjunct  to  local  treat- 
ment." 

Leprous  nodules  occasionally  develop  in  the  cor- 
neal tissues. 

An  opacity  and  insensibility  of  the  cornea  is  an 
evidence  of  death  which  might  be  of  service  in  a 
doubtful  case. 


CHAPTER    II. 

AFFECTIONS  OF    THE   EXTERNAL  OCULAR   MUSCLES. 

Paralytic  and  spasmodic  affections  of  the  external 
eye  muscles  occur  with  various  intra-cranial  and  spinal 
diseases,  and  while  they  are  usually  associated  with 
other  symptoms  which  indicate  with  more  or  less  pre- 
cision the  situation  and  nature  of  the  lesion,  the  eye 
symptoms  alone  will  often  furnish  valuable  diagnostic 
indications. 

A  spasm  of  a  given  muscle,  or  group  of  muscles, 
is  produced  by  an  irritation  of  a  locality  whose  destruc- 
tion causes  a  paralysis  of  the  same  part.  It  is  self- 
evident  that  a  nerve  may  be  excited  or  depressed  in 
any  portion  of  its  course  from  its  ultimate  distribution 
to  its  termination  in  the  cells  of  the  cerebral  cortex. 
Hence  an  accurate  knowledge  of  the  minute  anatomy  of 
the  ocular  motor  nerves  is  a  necessary  preliminary  to  a 
discussion  of  this  branch  of  the  subject.  Therefore  for 
the  sake  of  clearness,  I  will  repeat  here  what  may  be 
familiar. 

/  The   third,  fourth,    sixth,  facial   and  sympathetic, 

/it  will  be  remembered,  are  the  motor  nerves  of  the  eye. 
With  the  exception  of  the  sympathetic,  they  can  all  be 

traced  to   the   gray  matter   of   the   aqueduct  of   Sylvius^ 

(27) 


28  THE   EYE   AS   AN   AID   IN  GENERAL  DIAGNOSIS. 

and  to  that  of  the  fourth  ventricle.  The  nuclei  of  ori- 
gin of  both  third  nerves  anastomose  freely,  and  that  of 
the  abducens  communicates  with  the  third  and  the  ad- 
jacent nuclei  of  the  seventh  and  ninth.  From  here  the 
fibres  of  the  third,  or  motor-oculi-communis,  pass 
through  the  cms  cerebri  and  emerge  at  its  inner  side 
just  in  front  of  the  pons.  Those  of  the  fourth  wind 
around  the  cms  and  emerge  at  its  outer  edge,  and  those 
of  the  sixth  pass  downward  through  the  pyramids  of 
the  medulla  and  appear  at  the  lower  posterior  edge  of 
the  pons.  Thence  these  three  nerve  tracks  extend 
along  the  base  of  the  brain,  pass  through  the  cavernous 
sinus,  where  the  third  and  sixth  receive  communicating 
filaments  from  the  carotid  plexus,  and  enter  the  orbit 
through  the  supra-orbital  fissure.  The  terminal  fibres 
of  the  third  nerve  are  distributed  to  the  superior,  infe- 
rior and  internal  recti  muscles,  the  inferior  oblique,  the 
levator  palpebrae  superioris,  the  ciliary  muscle,  and  the 
sphincter  iridis.  The  individual  bundles  of  fibres  inner- 
vating these  various  muscles  have  been  traced  to  a 
series  of  centres  in  the  aqueduct  of  Sylvius,  which  are 
arranged  in  the  following  order  from  before  backward, 
viz.  : 

1.  Ciliary  muscle. 

2.  Sphincter  iridis. 

3.  Levator  palpebrae. 

4.  Rectus  internus  and  superior. 

5.  Rectus  inferior  and  obliquus  inferior. 


AFFECTIONS   OF   THE   EXTERNAL   OCULAR  MUSCLES.         29 

These  several  nuclei  of  origin  may  be  simulta- 
neously or  individually  diseased,  as  will  be  mentioned 
later  in  detail. 

The  fourth  nerve,  or  patheticus,  is  distributed  to 
the  superior  oblique,  and  the  fibres  of  the  sixth  pass  to 
the  external  rectus. 

The  facial  nerve  arises  from  the  floor  of  the 
fourth  ventricle,  and  it  emerges  at  the  posterior  border 
of  the  pons,  passes  through  the  Fallopian  canal  of 
the  petrous  bone,  and  makes  its  exit  through  the  sty- 
loid foramen,  from  which  point  it  spreads  out  over  the 
face,  and,  among  other  muscles,  is  distributed  to  the 
frontalis  and  the  orbicularis  palpebrarum. 

The  motor  fibres  of  the  sympathetic  arise  from 
the  lowermost  portion  of  the  cervical  cord,  and,  in  their 
course  to  the  eye,  pass  through  the  superior  cervical 
ganglion  and  the  carotid  plexus,  and  are  distributed  to 
the  unstriped  fibres  in  the  orbit  constituting  Miiller's 
muscle,  whose  contraction  dilates  the  palpebral  fissure, 
and   to  the  dilator  fibres  of  the  iris. 

f  From    these    contiguous    nuclei    of    origin    fibres 

I  pass  to  the  higher  centres  in  the  cerebral  cortex,  gov- 
'  erning  the  voluntary  and  associated  movements  of  the 
eyes.  Bearing  thus  in  mind  the  origin  and  course  of 
the  fibres  of  the  different  motor  nerves  of  the  eyeball,  a 
study  of  the  variety  and  relations  of  the  ocular  motor 
disorders  enables  one  to  arrive  at  a  more  accurate  diag- 
nosis of  the  situation  of  a  lesion  than  would  be  possible 
without  such   knowledo^e. 


so 


THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 


It  is   important   to  remember,  in   making  a  diag- 
nosis of  a  cerebral  affection  from  ocular  symptoms,  that 


Fig.  I.— Diagram  of  Base  of  the  Brain  and  Cranial  Nerves,  Pons  and  Medulla 
taken  from  "Diseases  of  the  Eye,"  by  H.  D.  Noyes,  M.  D.  I  to  XII,  The  Cranial 
Nerves ;  Th.  optic  thalamus  ;  h.  pituitary  body  ;  tc.  tuber-cinereum  ;  a.  corpora  albi- 
-cantia  (mammillaria)  ;  P.  pes  pedunculi ;  i.  internal  geniculate  body  ;  e.  external 
geniculate  body  ;  PV.  pons  Varolii ;  pa.  anterior  pyramid  of  medulla  ;  o.  olive ;  d. 
decussation  of  anterior  pyramids;  ca.  anterior  column  of  spinal  cord;  cl.  lateral 
column  of  spinal  cord  ;  Ce.  cerebellum  \fl.  flocculus  of  cerebellum  ;  X  locus  perfo- 
ratus  posticus;  +  (on  the  left  side),  ganglion  of  Oasser ;  +  (on  the  right  side), 
motor  root  of  trigeminus. 

parts   remote   from    the   primary  lesion   frequently  suffer 
temporarily.      This  is   especially  true  of   apoplectic   and 


PARALYTIC  AFFECTIONS.  31 

inflammatory  conditions.  The  permanent  symptoms, 
therefore,  are  the  only  ones  upon  which  an  accurate 
localization  may  be  based. 

PARALYTIC  AFFECTIONS. 

I  will  first  consider  the  significance  of  paralytic 
affections  of  the  extrinsic  eye  muscles,  leaving  for  future 
discussion  paralysis  of  accommodation  and  of  the  iris. 
The  diagnosis  of  a  total  paralysis  of  an  ocular  muscle 
presents  no  difficulty.  It  is  at  once  evident,  by  the  in- 
ability to  turn  the  eye  in  the  direction  of  the  paralyzed 
muscle,  and  by  the  squint  caused  by  the  unopposed  action 
of  its  opponent.  It  is  otherwise  when  there  is  incom- 
plete loss  of  function.  Often  there  is  no  apparent  loss 
of  motion,  and  the  paresis  is  only  manifested  by  the 
resulting  diplopia.  That  is  only  noticed  when  the  eye 
is  turned  in  the  direction  of  the  weak  muscle  and 
results  from  inharmonious  action  with  its  fellow  of  the 
opposite  eye,  so  that  there  is  inaccurate  binocular  fixa- 
tion of  an  object.  In  consequence,  the  retinal  images 
are  not  formed  upon  corresponding  portions  of  each  ret- 
ina, and  the  aerial  projection  of  the  images  are  not 
identical,  and  so  an  apparent  doubling  of  the  object  re- 
sults. The  following  directions  for  detecting  a  paresis 
of  the  ocular  muscles  are  so  admirably  expressed  that  I 
cannot  do  better  than  to  quote  them,  although  I  regret 
that  I  cannot  state  the  name  of  the  author  who  formu- 
lated them: 


32  TBE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

"  In  determining  which  rectus  muscle  is  affected, 
there  are  two  things  to  be  determined.  First,  the  part 
of  the  field  in  which  the  doubling  occurs ;  secondly,  the 
eye  which  sees  the  furthest  removed  object.  The  afiected 
muscle  is  always  on  that  side  of  its  eye  towards  which 
the  doubling  takes  place,  and  it  belongs  to  the  eye  that 
sees  the  furthest  removed  object.  To  illustrate :  Sup- 
pose that  the  patient  has  single  vision  immediately  in 
front  and  to  the  right,  but,  on  moving  the  candle  in 
the  horizontal  plane  to  the  left,  doubling  takes  place. 
At  once  we  are  able  to  say  that  the  affected  muscle  is 
either  the  external  rectus  of  the  left,  or  the  internal 
rectus  of  the  right  eye.  Since  the  affected  muscle  be- 
longs to  the  eye  that  sees  the  object  furthest  removed, 
it  only  remains  for  us  to  cover  one  eye  or  the  other, 
and  learn  from  the  patient  which  object  disappears. 
On  covering  the  right  eye,  if  the  object  furthest  re- 
moved is  blotted  out,  then  the  affected  muscle  is  the 
internal  rectus  of  the  right ;  if  the  contrary,  then  the 
paretic  muscle  is  the  external  rectus  of  the  left. 

"If  the  doubling  takes  place  in  the  vertical 
plane,  single  vision  being  below  and  immediately  in 
front,  but  doubling  taking  place  as  the  candle  is  raised 
above  the  horizontal  plane,  the  affected  muscle  is  the 
superior  rectus  of  one  eye  or  the  other.  It  belongs  to 
the  eye  that  sees  the  higher  object.  If,  on  covering 
the   right  eye,  the  higher  object  disappears,  then   it  is 


PARALYTIC  AFFECTIONS.  33 

the  superior  of  the  right ;  if  the  contrary,  it  is  the 
superior  rectus  of  the  left. 

"  Paralysis  and  paresis  of  an  oblique  muscle  re- 
quires a  more  careful  study,  and  yet  it  is  comparatively 
easy  to  locate  the  affected  muscle.  If  a  candle  be  held 
vertically  before  such  a  pair  of  eyes  there  would  be 
doubling,  one  image  being  vertical  and  the  other  lean- 
ing, the  vertical  candle  being  seen  by  the  non-affected 
eye,  while  the  leaning  candle  is  seen  by  the  eye  to 
which  is  attached  the  affected  miiscle.  If  the  left  eye 
sees  the  leaning  candle,  and  the  inclination  is  towards 
the  right,  the  affected  muscle  is  the  superior  oblique  of 
that  eye.  If  it  leans  toward  the  left,  the  affected  mus- 
cle is  the  inferior  oblique  of  that  eye.  The  vertical 
meridian  of  the  eye  affected  is  always  turned  in  the  op- 
posite direction  to  the  leaning  of  the  candle." 

It  is  desirable  to  make  a  distinction  between 
paralysis  of  one  or  several  eye  muscles  and  ophthalmo- 
plegia. By  the  latter  term  is  understood  the  simulta- 
neous paralysis  of  those  muscles  of  both  eyes  which  are 
concerned  in  conjugate  movements,  for  instance,  the  ex- 
ternal rectus  of  the  right  and  the  internal  rectus  of  the 
left  eye,  by  the  aid  of  which  both  eyes  are  simulta- 
neously directed  upon  an  object  on  the  right  side. 
Such  conjugate  paralyses  are  of  necessity  of  intra-cere- 
bral  or  cortical  origin,  and  a  distinction  should  be 
drawn  between  associate  and  conjugate  paralyses,  as 
will  be  referred  to  later. 


34  THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

The  existence  of  conjugate  contraction  of  the  eyes 
is  also  of  diagnostic  significance.  This  is  reserved  for 
future  discussion  in  connection  with  spasmodic  affect- 
ions. 

In  a  given   case  of  external   ocular  paralysis,  our 

first  endeavor  is  to  ascertain  whether  it  is  peripheral, 
that  is  located  within  the  orbit,  basilar,  that  is  in  the 
path  of  the  nerve  along  the  base  of  the  skull,  or  intra- 
cerebral (fascicular,  nuclear  or  cortical). 

I.    PERIPHERAL    PARALYSES. 

An  ocular  paralysis  due  to  a  disease  of  the  orbit 
such  as  tumor,  periostitis,  cellulitis,  etc.,  will  be  unilat- 
eral and  associated  with  other  symptoms  such  as  pain, 
inflammation  of  lids  and  conjunctiva,  exophthalmus,  etc., 
and  there  will  be  an  absence  of  evidence  of  intra-cran- 
ial  and  cerebral  or  spinal  disease,  such  as  implication  of 
other  nerves,  vercigo,  drowsiness,  pupillary  phenomena, 
headache  or  mental  aberration.  In  cases  of  traumatic 
origin,  the  evidence  of  injury,  or  the  history  of  the  case 
will  be  decisive.  Sometimes  the  association  of  the  mus- 
cles affected  will  settle  the  diagnosis  of  its  peripheral 
nature,  as  for  instance,  if  the  inferior  oblique  and  the 
internal  ocular  muscles  (iris  and  ciliary)  are  affected 
without  implication  of  the  other  external  muscles.  This 
is  evident  if  we  remember  that  the  iris  and  ciliary  mus- 
cles are  supplied  by  the  short  ciliary  nerves,  coming 
from  the  ciliary  ganglion  situated  in  the  back  of  the 


EXTERNAL  OCULAR  PARALYSES  OF  BASILAR  ORIGIN.       35 

orbit,  between  the  optic  nerve  and  the  external  rectus, 
and  that  the  motor  fibres  of  the  ciliary  ganglion  are  de- 
rived from  the  branch  of  the  motor-oculi  which  supplies 
the  inferior  oblique,  after  its  division  from  the  main 
trunk.  Diphtheria  is  a  cause  of  ocular  paralysis  which 
is  often  due  to  a  peripheral  neuritis. 

EXTERNAL    OCULAR    PARALYSES  OF  BASILAR  ORIGIN.  , 

A  lesion  at  the  base  of  the  brain  producing  ocu- 
lar paralysis  would  almost  of  necessity  affect  other 
nerves — the  fifth,  seventh,  optic  and  olfactory,  either 
simultaneously  or  successively — so  that  the  diagnosis 
would  rest  upon  the  association  of  other  symptoms,  es- 
pecially of  hemianopic  visual  disturbances  from  compres- 
sion of  one  optic  tract.  The  absence  of  such  symptoms 
would  afford  negative  evidence  against  the  basilar  situa- 
tion of  the  causative  lesion.  When  the  trigeminus  is 
paralyzed  by  a  basilar  affection,  it  is  preceded  by  neu- 
ralgia, which  is  not  the  case  when  it  is  of  cortical 
origin.  An  isolated  paralysis  of  the  third  nerve  due  to 
an  intra-cranial  basilar  lesion  is  possible,  but  it  affords 
no  data  for  a  positive  diagnosis.  The  absence  of  impli- 
cation of  the  iris  and  ciliary  muscle  would  counter-indi- 
cate a  basilar  origin,  as  all  the  fibres  from  the  separate 
nuclei  of  origin  are  united  when  the  nerve  emerges 
from  the  crus. 

Simultaneous  paralysis  of  both  third  nerves 
might  result  from   the  pressure  of  a  tumor,  a  syphilitic 


B6  THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

g^mma  for  instance,  between  the  cerebral  peduncles 
(crura  cerebri),  or  from  an  aneurism  of  the  posterior 
cerebral  artery.  A  thrombosis  of  one  cavernous  sinus, 
or  an  aneurism  of  one  internal  carotid  might  cause  total 
paralysis  of  the  muscles  of  one  eye,  but  as  the  ophthal- 
mic division  of  the  fifth  nerve  also  passes  through  the 
cavernous  sinus,  anaesthesia  of  the  parts  supplied  by  this 
nerv'^e,  lids,  conjunctiva,  nasal  fossae  and  integument  of 
the  eyebrows,  forehead  and  nose,  would  accompany  the 
motor  disorder. 

INTRA-CEREBRAL   PARALYSES,    INCLUDING   AFFECTIONS 

OF   THE   CRURA   (FASCICULAR   PARALYSIS),   OF 

THE    PONS,    NUCLEI    AND    CORTEX. 

ALTERNATING   PARALYSES. 

The  fibres  of  the  motor  nerves  of  the  extremities 
decussate  in  the  medulla,  those  originating  in  the  right 
hemisphere  being  distributed  to  the  left  side  of  the  body 
and  vice  versa.  The  motor  nerves  to  the  ocular  muscles 
decussate  higher  up.  Hence  the  existence  of  "alternate 
paralysis,"  by  which  is  meant  paralysis  of  one  or  both 
eyes  on  one  side,  and  of  the  extremities  on  the  other 
side,  indicates  that  the  lesion  is  between  the  medulla 
and  the  point  of  decussation  of  the  ocular  motor  nerves, 
viz. :  either  in  the  crus  or  the  pons. 

The  ocular  symptoms  may  be  limited  to  one  eye 
or  affect  both.  A  lesion  (hemorrhage,  abscess,  tumor), 
limited  to  one   crus  or  to  the   base  of   the   brain  imme- 


INTRA-CEREBRAL  PARALYSES,  ETC.  37 

diately  beneath  it  is  extremely  rare.  It  would  occasion 
paralysis  of  the  motor-oculi  on  the  side  opposite  the 
hemiplegia.  If  the  iris  and  ciliary  muscle  were  not  im- 
plicated, the  lesion  could  be  definitely  located  within 
the  crus,  because  the  fibres  from  the  anterior  nucleus 
are,  in  that  location,  still  considerably  separated  from 
the  others. 

A  paralysis  of  one  external  rectus  and  of  the  ex- 
tremities on  the  opposite  side  indicates  a  lesion  at  the 
posterior  edge  of  the  pons.  So,  also,  an  isolated  lesion 
of  one  sixth  nerve,  must  be  referred  to  a  lesion  in  one 
side  of  the  pons.  Since  the  sixth  and  facial  have  a 
common  origin  in  the  gray  matter  in  the  floor  of  the 
fourth  ventricle,  a  nuclear  lesion  must  affect  both  nerves. 

An  alternating  paralysis  caused  by  a  lateral  le- 
sion of  the  pons  is  manifested  by  ophthalmoplegia,  or 
loss  of  the  conjugate  movement  of  both  eyes  toward  the 
sound  side  of  the  body.  The  eyes  would  deviate  toward 
the  paralyzed  side  from  unrestrained  action  of  the  oppo- 
site muscles,  and  therefore  the  lesion  is  on  the  oppo- 
site side  of  the  pons  from  that  toward  which  the  eyes 
deviate.  Conjugate  deviation  of  the  eyes  also  occurs  as 
a  temporary  symptom  in  most  cases  of  apoplexy,  but 
when  the  hemorrhage  is  in  one  of  the  cerebral  hemi- 
spheres, the  paralysis  is  not  alternate,  because  the  lesion 
is  above  the  decussation  of  the  oculo  motor  nerves,  and 
therefore  the  eyes  and  the  extremities  are  paralyzed  on 
the  same  side.     Therefore,  the  inclination  of  the  eyes  is 


38  THE   EYE   AS  AN   AID   IN   GENERAL   DIAGNOSIS. 

of  diagnostic  importance  in  locating  the  situation  of  an 
apoplexy. 

If  the  eyes  turn  toward  the  paralyzed  side,  we 
have  an  alternating  paralysis,  and  the  lesion  is  in  the 
pons  on  the  opposite  side.  If  the  eyes  turn  toward  the 
sound  side,  the  hemorrhage  is  in  one  or  other  hemi- 
sphere above  the  pons,  and  on  the  same  side  toward 
which  the  eyes  turn. 

A  deviation  of  the  eyes  from  the  side  of  a  cere- 
bral lesion  may  exist  from  simple  conjugate  spasm  of 
the  ocular  muscles,  owing  to  an  irritation  in  the  vicin- 
ity of  the  visual  sphere  in  the  occipital  cortex  of  the 
opposite  side,  thus  simulating  the  condition  found  in 
diseases  of  the  pons.  The  unimpared  ability  to  move 
the  eyes  in  the  opposite  direction  will  demonstrate  the 
absence  of  paralysis,  and  the  limbs  on  the  side  toward 
which  the  eyes  are  turned  will  also  be  in  a  rigid,  spas- 
modic condition,  in  contrast  with  the  flaccid  paralyzed 
state. 

Another  indication  of  disease  of  pons  is  an 
associate  paralysis  of  the  eyes.  This  differs  from  the 
conjugate  paralysis  just  referred  to  in  that  the  paralysis 
of  the  affected  muscles  is  not  complete.  In  conjugate 
paralysis  toward  the  left,  for  instance,  both  eyes  are 
turned  to  the  right,  and  cannot  be  moved  at  all  in  the 
opposite  direction.  In  associate  paralysis,  on  the  other 
hand,  they  can  be  turned  to  the  left  as  far  as  the  mid- 
dle   line,  but   no   farther.     Such    cases   have   been  occa- 


INTRA-CEREBRAL  PARALYSES,  ETC.  39 

sionally  observed,  but  no  satisfactory  explanation  of 
their  cause  was  offered  until,  in  1879  <^^  1880,  Duval 
discovered  a  bundle  of  fibres  proceeding  from  the  nu- 
cleus of  origin  of  the  abducens  to  the  oculo-motorius  of 
the  opposite  side.  Later,  a  case  of  associate  paralysis 
was  reported  by  Ferreol,  in  which  an  autopsy  disclosed 
a  small  tumor  in  the  immediate  vicinity  of  origin  of 
the  sixth  nerve.  Stellwag  saw  this  peculiar  condition 
in  a  case  of  Basedow's  disease.  Gowers  locates  a  lesion 
causing  such  associate  paralysis  in  the  tegmental  region 
of  the  pons  on  one  side,  above  and  adjacent  to  the  nu- 
cleus of  the  sixth  nerve.  If  the  nucleus  of  the  sixth 
nerve  were  involved,  the  palsy  of  the  external  rectus 
would  be  complete,  so  that  that  eye  could  not  be  turned 
outward  at  all,  even  as  far  as  the  middle  line.  Inas- 
much also  as  the  internal  rectus  receives  special  direct 
innervation  from  the  third  nucleus,  it  is  not  incompati- 
ble with  associate  paralysis,  that  contraction  of  the  im- 
paired internal  rectus  should  be  retained  in  convergence 
of  the  visual  axes,  or  that  this  eye  should  turn  in  con- 
nection with  its  fellow,  whose  external  rectus  is  im- 
paired, as  far  as  the  middle  line  in  the  direction  of  the 
associate  paralysis. 

Two  other  varieties  of  this  associate  paralysis  in 
horizontal  movement  have  been  described,  the  one  by 
M.  Parinaud,  in  which  spasm  of  the  internal  rectus  ex- 
ists, and  the  other  by  Sauvineau,  in  which  spasm  of  the 
external  rectus   exists.     These   differences   are  explained 


40  THE   EYE   AS   AN   AID  IN   GENERAL   DIAGNOSIS. 

by  a  slight  variation  in  the  situation  of  the  lesion,  so 
that  with  the  paralysis  for  lateral  associated  movement 
there  is  an  irritation  of  one  or  the  other  nerve.  Thus 
both  associate  and  conjugate  paralysis  point  to  a  lesion 
in  the  corresponding  side  of  the  pons.  There  is  some 
reason  to  believe  that  the  pons  also  contains  centres 
which  preside  over  the  associated  lateral  and  vertical 
movements  of  the  eyes. 

"  Paralysis  of  both  upward  and  downward  move- 
ments of  the  eyes,  bilateral  and  accompanied  with  pto- 
sis, has  been  observed  with  disease  of  the  corpus  stri- 
atum and  optic  thalamus.  Loss  of  conjugate  movement 
upwards  has  been  caused  by  a  lesion  of  the  tubercula 
quadrigemina."     (Gowers). 

Verray  reported  such  a  case  accompanied  with 
tendency  to  deviate  toward  the  left  when  walking.  The 
affection  came  on  suddenly  and  was  attributed  to  a 
small  hemorrhage  in  the  tubercula  quadrigemina.  See 
^' Eevue  Med.  de  la  Suisse  Bomande"  March,  1893. 

"  Beckheim  believed  that  the  superior  olive 
(which  extends  the  whole  length  of  the  pons)  acted  as 
a  reflex  centre  for  correlating  movements  of  the  head 
and  eyes  with  auditory  impressions,  and  its  lesion 
might  therefore  be  expected  to  interfere  with  such  cor- 
relations, causing  a  lack  of  response  by  the  head  and 
eyes  to  sounds  coming  from  various  directions."  (Chas. 
K.  Mills  in  "  Intetnational  Clinics,"  October,  1895). 
Such   a   centre    for   reflex    movements   of   the  head  and 


NUCLEAR  PARALYSES.  41 

•eyes  in  connection  with    auditory   impressions  has   been 
referred  to  the  internal   geniculate  body. 

NUCLEAR   PARALYSES. 

A  nuclear  paralysis  may  affect  one  or  both  eyes, 
"but,  owing  to  the  free  communication  between  the  nu- 
clei of  the  opposite  sides,  the  latter  is  more  frequent. 
As  has  been  previously  mentioned,  the  motor-oculi 
arises  from  separate  nuclei  in  the  aqueduct  of  Sylvius. 
Hence  an  isolated  paralysis  of  one  or  more  of  the 
branches  of  the  nerve,  or  their  successive  implication, 
points  unmistakably  to  a  nuclear  lesion.  Not  infre- 
quently, the  intra-ocular  muscles  escape,  because  their 
motor  fibres  receive  a  separate  vascular  supply.  A  total 
paralysis  of  all  the  muscles  of  both  eyes  is,  in  all  prob- 
ability, of  nuclear  origin.  The  only  other  explanation 
is  a  separate  lesion  involving  each  cavernous  sinus  or 
each  optic  foramen. 

CORTICAL   OCULAR   PARALYSES. 

The  course  of  the  nerve  fibres  between  their  nu- 
clei of  origin  and  the  cortical  visual  centres  has  not 
been  anatomically  demonstrated,  and  we  have  no  data 
for  differentiating  ocular  paralyses  due  to  lesions  in 
these  two  localities,  i.  e.,  cortical  or  fascicular.  They  are 
always  binocular  and  conjugate.  Each  visual  area  not 
only  receives  impressions  from  the  opposite  half  fields  of 


42  THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

vision  of  the  two  eyes,  but  also  presides  over  the  volun- 
tary, conjugate  movements  in  the  same  direction.  An 
irritation  at  a  given  point  of  the  occipital  cortex,  as  has 
been  mentioned,  causes  deviation  of  both  eyes  toward 
the  particular  part  of  the  opposite  visual  field  which  is 
in  anatomical  relation  with  that  spot  (conjugate  spasm), 
'and  a  circumscribed  lesion  results  in  hemianopic  visual 
defects  and  corresponding  loss  of  conjugate  movement. 
The  visual  centre  on  the  right  side  is  associated  with 
the  left  half  fields  of  vision  and  with  conjugute  move- 
ments toward  that  side,  and  \'ice  versa.  Therefore  the 
lesion  is  always  on  the  side  opposite  the  paralysis,  and 
the  eyes  deviate  toward  the  side  of  the  lesion. 

There  are  two  features  which  are  characteristic 
of  cortical  ophthalmoplegias,  and  which  serve  to  distin- 
guish them  from  similar  motor  defects  due  to  lesions  of 
the  pons. 

First,  involuntary  and  reflex  movements  are  pre- 
served. If  a  strong  light  is  thrown  into  one  or  both 
eyes  from  the  paralyzed  side,  they  will  turn  in  the  di- 
rection of  the  light,  that  is,  in  the  direction  in  which 
voluntary  movement  is  lost.  The  same  occurs  under 
the  impulse  of  a  sudden  command  or  a  loud  noise. 
Such  involuntary  movements  are  absent  in  all  cases 
where  the  lesion  is  at  or  below  the  nuclei. 

Second,  cortical  paralyes  are  associated  with  vis- 
ual disturbances  and  pupillary  conditions  which  are  of 
great  value  in   locating  the   causative   lesion,  but   a  dis- 


COBTICAL  OCULAR  PARALYSES.  43 

cussion  of  such  symptoms  will  be  reserved  for  a  subse- 
quent chapter. 

Dissociate  paralyses,  that  is,  of  individual  muscles 
not  concerned  in  associate  movements,  are  also  of  cen- 
tral origin. 

In  muscular  affections  due  to  central  disease  there 
is  very  great  difficulty  in  overcoming  the  resulting  di- 
plopia. Even  with  carefully  selected  prisms,  the  patient 
finds  it  almost  impossible  to  unite  the  double  images. 

Having  said  so  much  in  regard  to  the  localiza- 
tion of  a  lesion,  let  us  now  inquire  whether  the  eye 
symptoms  furnish  any  evidence  of  the  nature  of  the  dis- 
eased process.  We  cannot  state  from  the  presence  of 
ocular  palsy  alone  that  there  exists  hemorrhage,  embo- 
lism, thrombosis,  meningitis,  tumor,  neuritis,  effusion  of 
lymph  serum  or  pus,  softening  or  sclerosis,  any  one  of 
which  may  be  the  cause  of  the  existing  symptoms,  but 
still  these  same  ocular  palsies  do  often  point  toward  the 
nature  as  well  as  the  location  of  the  central  lesion. 

A  sudden  lesion,  developing  immediately  or  with- 
in a  few  hours  and  causing  paralysis,  is  always  a  vas- 
cular one,  either  a  hemorrhage  or  an  occlusion.  An 
acute  lesion,  developing  in  a  few  days  or  weeks,  is 
probably  inflammatory.  A  chronic  one  indicates  degen- 
erative processes  or  gradual  pressure  from  a  neoplasm. 

Ocular  paralyses  in  children,  without  obvious 
cause,  is  to  be  regarded  as  a  very  serious  premonition 
of    tubercular    meningitis.      Such    a    case    occurred    not 


44  THE   EYE   AS   AN   AID   IN  GENERAL   DIAGNOSIS. 

long  since  in  my  practice.  I  was  consulted  simply  for 
the  secondary  squint.  I  declined  to  operate,  and  gave  a 
guarded  prognosis,  and  within  a  few  months  the  child 
died  with  unmistakable  signs  of  this  affection.  Such 
symptoms  are  much  less  frequently  associated  with  sim- 
ple meningitis. 

In  adults  ocular  paralyses  are  very  suggestive  of 
cerebral  syphilis.  Von  Graefe  says  that  one-third  of  all 
ocular  paralyses  are  due  to  syphilis.  The  proportion 
has  been  estimated  as  high  as  one-half.  They  occur 
usually  in  the  later  stages  of  the  disease.  The  third 
nerve  is  affected  in  three-quarters  of  such  cases  and  the 
sixth  in  one-quarter.  It  may  be  a  nuclear  lesion,  a 
neuritis  of  the  trunk  or  root  of  the  nerve,  or  it  may  be 
compressed  in  its  course  along  the  base  of  the  brain  by 
a  gumma.  Such  a  paralysis  may  be  the  initial  symp- 
tom of  cerebral  syphilis.  One  variety,  where  several 
muscles  of  both  eyes  are  affected  successively  and  trans- 
iently, varj'ing  in  degree  and  duration,  is  considered  al- 
most pathognomonic  of  the  cerebral  form  of  this  dis- 
ease. Anaesthesia  or  dysaesthesia  of  the  skin  of  the  face 
frequently  accompanies  syphilitic  ocular  palsies. 

Ocular  palsies  with  similar  manifestations  are 
also  very  frequent  in  locomotor  ataxia,  or  tabes  dorsalis. 
They  may  be  an  early  or  late  feature  of  the  case.  Fre- 
quently, as  in  one  case  coming  under  my  observation, 
they  preceded  for  some  time  the  other  developments  of 
the  disease.     Mott  in  "  International  Clinics,"  1895,  Vol. 


CORTICAL  OCULAR  PARALYSES.  45 

I,  page  127,  says  that  25  per  cent,  of  the  cases  com- 
mence with  ocular  paralysis.  Two  varieties  are  consid- 
ered suspicious,  viz.,  "  insignificant  paresis  which  easily 
recovers,  but  soon  reappears  in  one  or  the  other  eye. 
In  other  cases  there  quickly  becomes  associated  with 
a  perhaps  trifling  paresis  of  the  abducens,  a  contraction 
of  the  internal  rectus."  (Mauthner's  "  Gehirn  und 
Auge  ").     Such  cases  are  very  obstinate  to  treatment. 

It  is  estimated  that  from  20  to  40  per  cent,  of 
the  cases  of  tabes  are  accompanied  with  ocular  palsies, 
which  are  of  sudden  development  and  of  transient  dura- 
tion with  frequent  relapses.  One  or  both  eyes  may  be 
affected.  Thus  we  see  that  the  symptoms  resemble  very 
closely  those  resulting  from  syphilis,  and  it  should  be 
remembered  that  most  tabetic  patients  have  at  some 
time  been  syphilitic. 

Authorities  differ  as  to  the  order  of  frequency  of 
the  involvement  of  the  muscles.  In  100  cases  of  tabes, 
Dillman  found  paresis  of  one  or  more  of  the  muscles 
supplied  by  the  third  nerve  26  times ;  abducens  paresis 
1 2  times ;  trochlearis  paresis  3  times.  Kahler,  on  the 
contrary,  considers  paralysis  of  the  external  rectus  of 
most  frequent  occurrence  and  of  the  levator  palpebrae 
next  in  frequency. 

Associate  paralysis  of  convergence  has  been 
noticed.  Knies  says :  "  Every  paralysis  of  an  ocular 
muscle  which  occurs  suddenly  in  a  healthy  person 
(without    injury,    apoplexy,    or    other    brain    symptoms, 


46  THE   EYE   AS   AN  AID   IN   GENERAL  DIAGNOSIS. 

diabetes,  mellitus  or  insipidus,  syphilis,  albuminuria, 
etc.)  arouses  the  suspicion  of  a  beginning  tabes,  especially 
if  it  recovers  in  a  comparatively  short  time  or  subse- 
quently relapses." 

Thus  in  the  majority  of  ocular  paralyses,  espe- 
cially in  adults,  we  shall  find  the  exciting  cause  to  be 
either  syphilis  or  tabes,  and  the  following  points  of  dif- 
ferential diagnosis  between  these  two  affections  as  for- 
mulated by  Foumier  in  the  "  Bull,  de  Med.,^^  1887,  is 
of  value,  although  not  of  universal  application : 

Tabes.  Syphilis. 

Often  only  a  single  muscle  Larger  number  of  muscles 
involved  (nerve  roots  chief-  involved  and  accompanied 
ly),  with  headache,  vertigo,  epi- 

leptic attacks,  aphasia,  men- 
tal disorders,  etc. 
Accommodation    intact    for     Accommodation  suffers  ear- 
a  long  time.  ly. 

Often  temporary,  sometimes  More  permanent  and  devel- 
lasting  but  a  few  hours.  op  more  gradually. 

Galezowski,  on  the  other  hand,  says  that  uni- 
lateral paralysis  of  accommodation  without  mydriasis  is 
often  the  first  sign  of  beginning  tabes,  and  is  associa- 
ted with  anaesthesia  of  patches  of  skin  in  the  temporal 
region.  Those  which  occur  early  in  the  disease  more 
frequently  recover  than  those  developing  later. 


CORTICAL  OCULAR  PARALYSES.  47 

Multiple  sclerosis  and  general  paresis  also  give 
rise  to  ocular  paralyses  of  similar  character.  Other 
symptoms  will  be  present  to  establish  a  differential 
diagnosis.  A  paralysis  of  both  external  recti  has  been 
noticed  as  an  early  manifestation  of   the  latter  affection. 

Disease  of  the  cerebral  vessels,  resulting  from 
diabetes  and  renal  affections,  may  be  the  cause  of  ocular 
paralysis,  and  hence  an  examination  of  the  urine  should 
not  be  neglected  when  a  satisfactory  explanation  has 
not  been  reached. 

Ocular  paralyses  may  be  rheumatic  and  may 
affect  a  single  muscle  or  several.  Usually  one  or  more 
contiguous  branches  of  the  nerve  are  involved,  the 
superior  rectus  and  the  levator  palpebrae  for  instance. 
They  follow  exposure,  are  associated  with  other  rheu- 
matic affections,  remote  or  present,  and  are,  as  a  rule, 
limited  to  one  eye,  whereas  ocular  paralyses  from  cen- 
tral disease  are  usually  bilateral.  Such  cases  are  gener- 
ally regarded  as  of  nuclear  origin.  Diphtheria  rarely 
causes  paralysis  of  the  external  eye  muscles.  Such 
cases,  when  they  do  occur,  are  usually  peripheral,  and 
are  the  sequence  of  hemorrhages  or  neuritis,  but  some- 
times they  are  nuclear.  They  occur  later  in  the  disease 
and  usually  slowly  recover.  An  ocular  paralysis,  due  to 
peripheral  neuritis,  is  most  frequently  caused  by  alcohol, 
and  we  should  expect  to  find  associated  symptoms  of 
peripheral  neuritis  in  other  localities. 


48  THE   EYE   AS   AN   AID   IN   GENERAL  DIAGNOSIS. 

PATHOLOGY  OF  NUCLEAR  PARALYSES. 

It  has  been  remarked  previously  that  progressive 
paralysis  of  the  different  branches  of  the  third  nerve,  or 
a  total  paralysis  of  all  the  muscles  of  both  eyes,  is  al- 
most conclusive  evidence  of  a  nuclear  lesion.  This  les- 
ion may  be  of  varied  nature ;  for  instance,  a  tubercular 
formation,  or  a  cyst  might  exist  in  this  situation  and 
produce  the  symptoms  by  pressure.  A  syphilitic  athero- 
matous degeneration,  or  an  embolism  of  one  of  the 
branches  of  the  basilar  arter}'  would  explain  such  a 
condition. 

Certain  toxic  substances,  notably  lead,  alcohol 
sulphuric  acid,  and  the  fumes  of  charcoal,  have  pro- 
duced nuclear  ocular  paralysis,  but  more  frequently  the 
resulting  eye  symptoms  in  such  cases  of  poisoning  are 
due  to  peripheral  neuritis. 

Acute  and  chronic  infectious  diseases  are  also  oc- 
casionally associated  with  nuclear  ocular  palsies.  They 
may  complicate  divers  affections,  notably  bulbar  paraly- 
sis, progressive  muscular  atrophy,  tabes  and  disseminate 
sclerosis. 

There  is  an  acute  and  a  chronic  form  of  nuclear 
paralysis.  An  acute  form  develops  in  intemperate  per- 
sons and  is  usually  fatal. 

Knies  says :  "  Progressive  paralysis  of  the  ocular 
muscles  is  an  essential  feature  of  polio-encephalitis 
superior,  or  inflammation  of  the  floor  of  the  fourth  ven- 


PATHOLOGY  OP  NUCLEAR  PARALYSES.         49 

tricle.  (Wernicke  was  the  first  to  differentiate  it).  The 
acute  hemorrhagic  form  is  usually  due  to  alcohol.  The 
chronic  form  is  the  more  frequent.  The  symptoms  are 
generally  bilateral,  are  irregular  in  development,  and  af- 
fect both  the  external  and  internal  muscles.  The  loss 
of  function  may  be  complete  or  partial.  It  is  rarely  an 
independent  disease.  Somnolence  is  an'  early  and  char- 
acteristic feature  which  serves  as  a  diagnostic  point  in 
distinction  from  simple  nuclear  paralyses." 

SPASMODIC  AFFECTIONS  OF  THE    EXTERNAL  OCULAR 
MUSCLES. 

It  has  been  previously  remarked  that  spasm  of 
one  or  more  of  the  ocular  muscles  is  caused  by  an  irri- 
tation of  the  same  locality  whose  destruction  causes 
paralj^sis.  Hence  no  further  discussion  of  the  localiza- 
tion of  cerebral  affections,  as  indicated  by  ocular  spas- 
modic affections,  is  necessary.  A  single  muscle  or  a 
group  of  muscles  may  be  affected  by  irritation  of  a 
nerve  at  its  nucleus,  or  at  its  cerebral  termination.  Cor- 
tical spasms  are  always  binocular  and  conjugate.  As 
has  been  remarked  in  discussing  paralytic  affections,  the 
secondary  deviation  of  the  eyes  in  cases  of  cerebral  ap- 
oplexy, indicates  the  side  of  the  brain  affected.  The 
eyes  point  toward  the  side  of  the  lesion  unless  the 
hemorrhage  is  in  the  pons  or  crus,  when  the  eyes  and 
extremities  are  paralyzed  on  opposite  sides,  and  the  eyes 

deviate  toward   the   unaffected  side  of  the  brain. 
4 


60  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Since  muscular  spasms  are  the  expression  of 
cerebral  irritation,  we  should  expect  to  meet  with  them 
in  hyperaemic  and  inflammatory  affections  of  the  brain 
and  meninges.  Strabismus  is  frequent  in  cerebro-spinal 
and  basilar  meningitis.  It  is  not  infrequently  caused  by 
reflex  irritation  from  the  teeth  and  digestive  organs. 
This  will  be  more  specifically  considered  in  the  chapter 
on  reflex  neuroses.  There  is  one  form  of  spasm  which 
is  worthy  of  special  mention.  I  refer  to  nystagmus,  an 
oscillating,  to  and  fro  movement  of  the  eyeballs,  usually 
in  the  horizontal  plane,  and  caused  by  alternate  contrac- 
tion and  relaxation  of  the  external  and  internal  recti. 
This  condition  may  be  congenital  or  developed  in  early 
childhood.  It  then  indicates  simply  a  lack  of  voluntary 
control  of  the  muscles,  which  is  acquired  by  the  child 
simultaneously  with  intelligent  vision.  As  soon  as  he 
recognizes  objects,  he  directs  the  eyes  toward  them, 
thereby  acquiring  the  faculty  of  accurate  fixation.  It  is 
easy  to  understand  that  this  faculty  will  be  imperfectly 
developed  if  vision  is  too  indistinct  to  create  cortical 
perceptions  definite  and  strong  enough  to  excite  the  im- 
pulse of  adjustment.  Hence  opacities  of  the  cornea  due 
to  ophthalmia  neonatorum,  and  congenital  cataract,  colo- 
boma  of  the  iris  and  choroid,  microphthalmus  and  high 
degrees  of  refractive  errors  are  among  the  recognized 
causes  of  congenital  or  infantile  nystagmus.  If  both  eyes 
are  imperfect,  the  nystagmus  is  constant,  but  if  one  eye 
only   suffers,    the   tremor  is  only  noticed  when  an  effort 


EXTERNAL  OCULAR  MUSCLES.  51 

is  made  to  fix  an  object  with  this  eye,  but  then  it  is 
bilateral.  It  may  also  result  from  arrested  development 
of  the  nerve  trunks  or  cortical  centres,  so  that  the  mo- 
tor stimulus  is  wanting  though  visual  impressions  are 
accurately  received  and  interpreted. 

Nystagmus  also  develops  in  persons  who  use 
their  eyes  for  long  periods  with  insufficient  light,  as  the 
so-called  "  Miner's  Nystagmus."  The  confinement  in 
dark,  ill-ventilated,  underground  chambers,  and  the 
breathing  of  poisonous  gasses,  added  to  the  strain  upon 
the  eyes,  consequent  upon  working  with  insufficient 
light  and  keeping  the  eyes  fixed  in  an  unnatural  posi- 
tion many  hours  a  day,  which  the  nature  of  the  work 
necessitates,  are  the  causes  of  this  affection.  Night 
blindness  often  develops  simultaneously. 

When  nystagmus  develops  in  adults,  who  are  not 
engaged  in  such  occupations,  it  is  a  valuable  diagnostic 
sign  indicating  the  existence  of  serious  organic  disease. 
But  it  affords  no  evidence  of  the  location  or  the  nature 
of  the  disease,  for  it  has  been  found  associated  with 
meningeal  and  subdural  hemorrhage,  pachy-meningitis- 
hemorrhagica,  in  tubercular  basilar  meningitis,  cerebral 
hemorrhage,  thrombosis  in  the  sinuses,  tumor,  softening, 
disease  of  the  optic  thalamus,  lesions  of  the  cerebellum, 
in  disease  of  one  side  of  the  pons,  and  in  degenerative 
diseases  of  the  cord.  Gowers,  in  the  last  edition  of  his 
"  Diseases  of  the  Nervous  System,"  says  :  "  The  practi- 
cal   significance    of    nystagmus    is    extremely   great,    not 


52  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

from  any  distinct  indication  of  the  seat,  or  precise  na- 
ture of  the  disease,  but  because  it  shows  the  presence  of 
more  tJtan  functional  disturbance.  It  is  often  marked  in 
the  early  stage  of  degenerative  disease  when  other 
symptoms  are  equivocal,  and  a  search  for  it  should 
never  be  omitted,  and  should  include  always  the  up- 
ward movement  of  the  eyes.  It  may  be  trusted  without 
hesitation,  and  in  a  large  number  of  cases  prevents  a 
mistake  in  diagnosis." 

It  occurs  very  frequently  with  multiple  sclerosis 
and  is  a  characteristic  symptom  and  a  valuable  diagnostic 
sign.  It  is  said  to  occur  in  12  per  cent,  of  all  cases 
of  this  disease.  When  tremor  of  the  eyes  on  fixing  an 
object  is  associated  with  true  nystagmus,  we  have  an 
additional  indication  of  multiple  sclerosis.  According  to 
Knies,  the  symptom  is  caused  by  sclerotic  foci  in  the 
vicinity  of  the  muscle  nuclei,  whereby  the  conduction 
is  interfered  with,  but  not  abolished.  In  other  cases  it 
indicates  incomplete  motor  paralysis  of  the  cerebral  cor- 
tex.    It  rarely  occurs  in  tabes  and  paralysis  agitans. 

"  Charcot  regards  nystagmus-like  twitching  of  the 
eyes,  that  is,  irregular  movements  when  an  object  is 
fixed,  as  a  valuable  diagnostic  sign  of  Friedreich's  dis- 
ease or  hereditary  ataxia,  which  begins  generally  at  the 
period  of  puberty."     (Knies). 

In  opposition  to  the  views  of  Gowers,  above  ex- 
pressed, that  the  presence  of  nystagmus  always  indicates 
an   organic   nervous   disease.    Dr.    Sabrazes,  in  ^^  Semaiiie 


EXTERNAL  OCULAR  MUSCLES.  53 

Medic,^^  for  September  26,  1894,  and  quoted  in  the  Eng- 
lish edition  of  ^^Annal  d'oculistique,^^  says  : 

"Is  acquired  nystagmus,  the  diagnostic  value  of 
which  I  am  about  to  sketch,  always  produced  by  a  per- 
manent organic  lesion?  May  there  not  be  cases  in 
which  the  successive  elimination  of  the  many  causes 
cited  to  explain  nystagmus,  lead  the  observer  to  suspect 
the  possibility  of  a  purely  functional  disturbance  arising 
from  hysterical  phenomena? 

"  This  is  not  the  opinion  of  neurologists,  and  par- 
ticularly of  Charcot,  who  said,  in  1892,  in  the  course  of 
a  lecture  on  multiple  sclerosis  and  its  ocular  phenom- 
ena :  '  Nystagmus  is  never  found  in  hysteria  or  in 
tabes.' 

"  But  the  existence  of  a  single  indisputable  case, 
carefully  observed,  suffices  to  controvert  this  too  strong 
assertion  and  to  show  that  an  hysterical  nystagmus  may 
really  exist. 

"  The  author  confirms  his  assertion  by  reporting 
a  case  of  manifest  hysteria  where  the  nystagmus  was 
independent  of  any  lesion  of  the  visual  apparatus.  Fur- 
thermore, hypnotic  suggestion  caused  the  disappearance 
of  all  symptoms  of  disease  as  soon  as  it  was  practiced. 

"  Nystagmus  should  not,  then,  be  taken  as  an 
absolute  proof  of  multiple  sclerosis  without  considering 
the  possibility  of  hysteria."     (Valude). 


CHAPTER  III. 

AFFECTIONS  OF  THE   LENS  AND   IRIS.      BEHAVIOR  OF 
THE    PUPIL   AND  OF  THE    ACCOMMODATION. 

AFFECTIONS  OF  THE   LENS. 

The  lens  derives  its  nourishment  from  the  arteries 
of  the  ciliary  processes.  A  lenticular  opacity  is  always 
an  evidence  of  impaired  nutrition  and  there  are  two  var- 
ieties of  cataract  which  are  of  special  diagnostic  signif- 
icance. 

I.  A  laminated  cataract  sometimes  occurs  in  young 
children  in  consequence  of  convulsions,  and  the  latter 
may  be  caused  by  rachitis.  An  explanation  has  been 
offered  upon  the  supposition  that  a  spasm  of  the  ciliary 
muscle  accompanies  the  general  convulsions,  and  thus 
interferes  with  the  circulation  in  the  arteries  of  the 
ciliary  processes.  The  development  and  growth  of  the 
lens  continues  up  to  the  sixth  year,  and  those  parts 
which  have  been  completely  formed  previous  to  the  oc- 
currence of  the  convulsions  remain  transparent,  while 
the  nutrition  of  the  portion  which  is  still  in  a  forma- 
tive stage  suffers  and  hence  is  more  or  less  cloudy. 
The  opacity  does  not  develop  immediately,  but  within  a 
few  days  or  weeks  subsequent  to  the  convulsion.    There- 

(54) 


AFFECTIONS  OF  THE  IRIS.  65 

fore  the  occurrence  of  a  laminated  cataract  indicates  the 
necessity  for  constitutional  treatment,  especially  with  ref- 
erence to  rachitis. 

II.  A  soft  or  cortical  cataract  in  older  children 
or  young  adults  is  frequently  caused  by  diabetes,  owing 
to  the  absorption  of  water  and  to  the  presence  of  glu- 
cose. Both  eyes  are  usually  affected.  Therefore  the 
urine  should  always  be  examined  in  such  cases. 

La  Grange  {^^  Arch.  d'Ophthal,"  1887,  Jan.)  found 
13  cases  of  cataract  among  52  diabetics,  and  Galezowski 
{^^Jahr.f.  Aug.,^^  1883,  p.  297)  found  46  cases  of  cata- 
ract in  144  diabetics. 

AFFECTIONS  OF  THE   IRIS. 

Inflammation  of  the  iris  (iritis)  always  arouses  a 
suspicion  of  syphilis,  and  there  is  one  form  of  the  affection 
which  warrants  a  positive  diagnosis  of  this  disease.  The 
proportion  of  cases  of  iritis  which  are  of  specific  nature 
has  been  estimated  by  various  writers  at  from  one-fourth, 
(Arlt),  to  three-quarters.  Probably  fifty  per  cent,  is  a 
safe  estimate.  Not  all  of  them,  however,  manifest  the 
characteristic  feature  giving  rise  to  the  classification  of 
"  gummous,"  "  condylomatous  "  or  "  papulous "  iritis. 
This  consists  in  the  development  of  "  yellow  or  dirty 
orange  colored  nodules,  surrounded  by  a  narrow  red 
zone  two  or  three  millimetres  in  diameter,  more  often 
toward  the  pupillary  margin  and  below."  The  reddish 
color   of   the   nodules   distinguishes   the   syphilitic   iritis 


66  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

from  the  tubercular  and  leprous  iritis,  in  which  there 
also  occurs  a  fonnation  of  tubercles  or  nodules.  The 
former  are  grayish  red  or  yellowish  white  in  color,  and 
are  not  much  larger  than  a  pin's  head.  There  are 
usually  several,  and  they  may  appear  and  disappear  for 
a  considerable  length  of  time.  Ludwig  Bach  makes  the 
assertion  in  Knapp's  Archives,  Jan.,  1895,  that  iritis  is 
just  as  often  of  tuberculous  as  of  syphilitic  origin,  but 
this  is  probably  an  exaggeration.  He  states  also  that  the 
ciliary  portion  of  the  iris  is  the  part  most  often 
affected  by  tuberculosis.  The  leprous  nodules  are  gray- 
ish in  color  and  are  situated  towards  the  outer  edge  of 
the  iris,  and  usually  grow  until  they  fill  the  anterior 
chamber  and  induce  secondary  cyclitis  and  irido-cyclitis, 
and  destruction  of  the  eye.  Leprosy  is  a  rare  disease  in 
this  country,  while  tuberculosis  is  common.  Probably 
iritis  is  never  a  primary  manifestation  of  either  disease, 
and  there  will  be  coexistent  symptoms  which  will  ren- 
der a  diagnosis  unequivocal. 

Syphilitic  iritis  is  most  frequently  observed  in  the 
secondary  stage  of  the  acquired  form.  It  has  been  ob- 
served within  three  weeks  after  the  appearance  of  the 
initial  lesion.  When  iritis  develops  in  children,  espe- 
cially in  infants,  it  is  usually  a  manifestation  of  heredi- 
tary lues. 

Sarcoma,  also,  sometimes  develops  in  the  iris, 
producing  symptoms  somewhat  analagous  to  those  of 
syphilis  and  leprosy.     The  color  of  the  growths  and  the 


AFFECTIONS  OF  THE  IRIS.  57 

course  of  development,  the  history  and  concomitant 
symptoms  will  decide  the  diagnosis. 

Diabetes  is  occasionally  associated  with  a  form  of 
iritis,  with  a  significant  symptom  of  an  unusually  exten- 
sive exudation,  purulent  or  fibrinous,  into  the  anterior 
chamber. 

Iritis  may  be  idiopathic,  and  cau.sed  by  exposure 
to  cold,  especially  in  rheumatic  subjects,  and  it  is  fre- 
quently associated  with  gonorrhoea.  Certain  conditions 
frequently,  though  not  invariably,  accompany  both  of 
these  varieties,  and  render  their  differential  diagnosis 
difficult  without  the  aid  of  other  symptoms.  Both  are 
prone  to  relapse,  and  are  accompanied  with  pain  and  in- 
flammation of  the  joints,  and  both  are  attended  with  a 
thick,  fibrinous,  easily  coagulating  exudation,  with  a 
tendency  to  firm  adhesion  to  the  lens  and  to  occlusion 
of  the  pupil. 

Distinguishing  features  of  the  rheumatic  form  are 
the  greater  severity  of  the  pain,  the  aggravation  from 
moving  the  eye,  and  the  rarity  of  suppuration. 

It  is  stated  that  iritis  often  complicates  relapsing 
fever,  and,  while  of  no  diagnostic  importance,  the  fact 
should  be  borne  in  mind  that  the  affection  may  be 
promptly  recognized  and  correctly  treated. 

Finally,  in  cases  of  iritis  without  obvious  cause, 
the  urine  should  be  examined,  for  it  has  been  ascribed 
to  albuminuria. 


58  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

BEHAVIOR   OF  THE   PUPIL  AND   OF   THE  ACCOMMODATION. 

Before  discussing  the  significance  of  pathological 
conditions  of  the  pupil,  a  few  words  regarding  its  natu- 
ral form  and  size,  and  the  methods  of  examination  are 
desirable. 

The  pupil  is  the  nearly  round  opening  in  the 
muscular  curtain  of  the  iris.  It  appears  black  under 
ordinary  circumstances  because  the  part  of  the  retina 
presenting  through  it  is  not  illuminated.  The  iris  is 
composed  of  both  radiating  fibres  whose  contraction  en- 
larges the  opening,  and  of  constrictor  fibres  by  means 
of  which  the  opening  is  made  smaller.  The  size  of  the 
pupil  therefore  varies  considerably  under  physiological 
conditions.  It  contracts  under  the  stimulus  of  light, 
upon  efforts  of  accommodation,  and  with  convergence, 
and  it  dilates  under  feeble  illumination,  and  upon  irri- 
tation of  the  skin,  especially  of  the  face  and  of  the  back 
of  the  neck.  It  is  larger  in  children  and  smaller  in  old 
age  than  in  adult  life.  It  is  also  slightly  larger  in  my- 
opia and  smaller  in  hypermetropia  than  in  emmetropia. 
The  diminution  of  accommodation  in  the  former  con- 
dition, and  its  increase  in  the  latter  is  the  explanation 
of  the  varying  size. 

Its  diameter,  under  ordinary  illumination,  is  from 
2.5  mm.-5.8  mm.,  with  an  average  of  about  4  mm.,  and 
a  constant  departure  from  this  standard  is  usually  an  indi- 
cation of  disease.     The  pupils  of  the  two  eyes  should  be 


BEHAVIOR  OF  PUPIL  AND  ACCOMMODATION.  59 

of  uniform  size,  although  very  careful  examination  fre- 
quently demonstrates  trifling  variations  not  apparent 
upon  ordinary  inspection,  and  they  should  react  con- 
sensually  and  equally  to  stimuli  applied  to  either  eye 
singly,  or  to  both  together.  When  only  one  pupil  is  il- 
luminated, for  instance,  both  should  contract  to  the  same 
extent.  If  any  inequality  is  noticed,  the  one  showing 
the  lesser  reaction  is  usually  the  pathological  one,  but 
this  is  not  invariable. 

The  behavior  of  the  pupils  is  of  very  great  prac- 
tical significance  in  the  diagnosis  both  of  the  location 
and  nature  of  nervous  diseases,  and  therefore  its  exami- 
nation should  be  conducted  systematically  and  with 
great  care.  The  following  method  is  recommended :  It 
is  assumed  that  any  inflammation  of  the  iris  or  posterior 
synechiae  is  absent,  and  that  the  media  are  clear.  The 
patient  being  seated  before  a  window  with  moderate 
illumination,  the  size  and  form  of  each  pupil  should 
be  separately  measured  with  a  rule  or,  preferably,  with 
a  pupillometer  constructed  especially  for  this  purpose, 
while  he  is  gazing  straight  before  him  at  a  distance. 
The  observation  should  be  made  when  both  eyes  are 
open,  and  when  they  are  alternately  closed  or  shaded, 
carefully  noting  any  movement  of  contraction  or  dilata- 
tion, and  any  lack  of  uniformity  in  such  movements  in 
the  two  eyes.  The  reaction  upon  convergence  and  ac- 
commodation is  now  studied  by  fixing  the  patient's  gaze 
upon    the    examiner's    finger,    which    is    gradually    ap- 


60  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

proached  along  the  middle  line  to  about  8  inches  in 
front  of  the  patient's  eyes.  To  study  the  accommoda- 
tive reaction  independently  of  convergence,  each  eye 
should  be  examined  separately.  The  one  under  observa- 
tion should  be  directed  straight  forward  and  the  other 
one  closed.  After  a  few  seconds  he  is  made  to  suddenly 
fix  his  gaze  upon  some  near  object,  without  altering  the 
direction  of  his  vision.  The  pupil  should  immediately 
contract,  and  dilate  again  as  soon  as  the  object  is  re- 
moved. 

The  light  reflex  is  best  observed  by  concentrating 
a  pencil  of  light,  preferably  from  an  artificial  source  of 
illumination,  upon  the  pupil  by  means  of  a  convex  lens, 
and  watching  the  resulting  contraction  of  each  pupil. 
The  eyes  are  to  be  separately  tested,  the  one  not  under  ob- 
servation being  shielded  from  direct  exposure  to  the  light, 
but  not  closed.  The  light  should  be  thrown  into  the  eye 
from  different  directions,  and  its  intensity  varied  to  test  the 
sensibility  of  different  portions  of  the  retina  and  the  de- 
gree of  such  sensibility.  These  tests  should  be  several 
times  repeated  in  obscure  cases,  when  the  result  of  the 
first  examination  is  not  conclusive,  and  it  is  often  ad- 
visable to  place  the  patient  in  a  darkened  room  for 
some  minutes  previously. 

Having  discussed  the  methods  of  examination, 
I  pass  to  what  may  be  learned  from  the  results  so  ob- 
tained. 


BEHAVIOR  OF  PUPIL  AND  ACCOMMODATION.  61 

Dilatation  and  contraction  of  the  pupils  may  be 
due  to  direct  stimulation  of  the  motor  nerves,  but  they 
are  usually  reflex  acts.  The  light  reflex,  the  skin 
reflex,  and  the  contraction  attending  efforts  of  accommo- 
dation and  convergence  have  been  already  mentioned. 

Mydriasis  and  myosis  have  no  special  significance 
as  isolated  symptoms,  but,  taken  in  connection  with 
other  symptoms,  they  are  sometimes  an  index  of  the 
nature  and  location  of  a  morbid  process,  and  the  differ- 
ent forms  of  paralysis  of  the  iris  muscles  are  very  sug- 
gestive diagnostic  indications,,  as  will  be  apparent  in  a 
later  discussion. 

If  we  recall  the  paths  which  the  afferent  and 
efferent  impulses  traverse  in  each  instance  of  reflex  and 
associated  action,  we  shall  more  clearly  understand  the 
morbid  processes  which  abolish  these  acts. 

I.  Contraction  of  the  Pupil — Contraction  of 
the  pupil  under  the  stimulus  of  light  (the  light  reflex)  is 
accomplished  by  an  afferent  impulse  passing  from  the 
retina  along  the  optic  nerve  and  optic  tract  to  the 
thalamus,  and  by  way  of  the  habenular  ganglion  to  the 
pineal  gland.  From  each  of  these  localities  (the  habenu- 
lar ganglion  and  the  pineal  gland)  fibres  pass  to  the 
oculo-motor  nucleus  in  the  aqueduct  of  Sylvius,  and 
from  thence  the  motor  impulse  travels  along  the  third 
nerve  to  the  ciliary  ganglion,  and  through  the  ciliary 
nerves  to  the  constrictor  fibres  of   the  iris. 


€2  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

The  consensual  reaction  of  the  pupils  is  ex- 
plained by  the  existence  of  communicating  branches  be- 
tween the  habenular  ganglia  in  either  hemisphere  of  the 
brain,  the  communication  taking  place  through  the  pos- 
terior commissure,  and  also  by  the  decussation  of  the 
optic  nerve  fibres  in  the  chiasm,  so  that  stimulation 
transmitted  from  the  retina  of  one  eye  reaches  the 
visual  centres  through  the  medium  of  both  optic  tracts. 
(Some  writers  locate  the  reflex  centre  from  the  iris  in 
the  anterior  corpora  quadrigemina  instead  of  the  haben- 
ular ganglion). 

It  is  evident  that  the  pupillary  light  reflex  will 
be  lost  whenever  the  conduction  fails  either  in  the  optic 
or  the  third  nerve. 

Accommodation,  or  the  adjustment  of  the  vision 
for  near  objects,  is  effected  by  contraction  of  the  ciliary 
muscle,  which,  as  well  as  the  iris,  is  under  control  of 
the  third  nerve.  An  act  of  accommodation  is  usually 
associated  with  contraction  of  the  pupil.  It  should  be 
remembered  that  this  is,  to  some  extent,  a  mechanical 
result  of  the  contraction  of  the  ciliary  muscle  whereby 
a  larger  amount  of  blood  is  forced  into  the  iris.  Both 
the  reflex  and  associated  contraction  fail  simultaneously, 
as  a  rule,  but  it  is  possible  for  the  latter  to  be  pre- 
served, when  the  light  reflex  fails,  constituting  the  so- 
called  "Argyll-Robertson  pupil,"  the  significance  of 
which  will  be  referred  to  later. 


BEHAVIOR  OF  PUPIL  AND  ACCOMMODATION.  63 

The  reflex  arc  by  which  the  pupillary  reaction 
attending  convergence  of  the  visual  axes  is  accomplished 
is  probably  completed  by  fibres  which  pass  from  the 
optic  tract  to  the  corpora  quadrigemina,  and  from 
thence  to  the  third  nucleus.  The  function  of  the  cor- 
pora quadrigemina  is  not  yet  positively  determined,  but 
it  seems  almost  certain  that  they  preside  over  "  ocular 
movements  in  their  relation  to  visual  impressions." 
(Gowers). 

2.  Dilatation  of  the  Pupil. — Dilatation  of  the 
pupil  results  passively  from  relaxation  of  the  sphincter 
pupillae,  and  actively  from  the  contraction  of  the  dilator 
fibres,  through  stimulation  of  the  sympathetic  nerves 
which  govern  them.  In  this  manner  direct  excitation 
of  the  cilio-spinal  centre  in  the  upper  dorsal  portion  of 
the  cord  produces  mydriasis,  and  irritation  of  the  skin 
has  also  this  effect,  by  reflex  action.  In  the  latter  case, 
the  afferent  impulse  reaches  the  corpora  quadrigemina 
through  the  spinal  cord,  and  the  motor  impulse  is 
thence  transmitted  again  through  the  upper  cervical 
cord  by  way  of  the  seventh  and  eighth  cervical  and 
first  dorsal  nerve  roots,  to  the  cervical  sympathetic, 
thence  to  the  cavernous  plexus,  ciliary  ganglion  and 
ciliary  nerves.  Some  of  the  sympathetic  fibres  reach 
the  iris  by  a  different  path,  as  is  proven  by  the  fact 
that  irritation  of  the  trunk  of  the  sympathetic  in  the 
neck  produces  dilatation  of  the  pupil  after  removal  of 
the    ciliary  ganglion.     The    ophthalmic    division   of  the 


64  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

fifth  nerve  is  one  of  the  channels  for  such  sympathetic 
influence. 

Thus  the  skin  reflex  will  be  lost  whenever  the 
conduction  fails  in  either  direction,  in  consequence  of  a 
lesion  in  the  upper  cervical  region  of  the  cord,  in  the 
cerv'ical  sympathetic,  or  along  the  path  between  the  lat- 
ter and  the  ciliary  ganglion.  When  the  light  reflex  is 
lost  in  diseased  conditions,  the  skin  reflex  generally  fails 
also,  but  not  always.  The  skin  reflex  may  be  preserved 
when  the  light  reflex  is  lost. 

As  of  diagnostic  significance  in  connection  with 
nervous  affections,  we  recognize  a  spastic  and  a  paretic 
variety  of  both  mydriasis  and  myosis,  and,  in  a  given 
case,  it  is  desirable  to  inquire  which   variety  exists. 

Mydriasis — The  spastic  variety  of  mydriasis  is 
caused  by  contraction  of  the  radiating  fibres  of  the  iris 
through  stimulation  of  the  sympathetic  motor  nerves. 
The  widely  dilated  pupil,  in  such  conditions,  still  con- 
tracts with  efforts  of  accommodation  and  upon  the  stimu- 
lus of  light,  showing  that  the  constrictor  fibres  and  the 
path  of  the  light  reflex  are  unaffected,  but  there  is  di- 
minished or  absent  contraction  from  the  use  of  myotics 
such  as  eserine  and  pilocarpine. 

Other  signs  of  sympathetic  irritation  are  also 
present,  such  as  dilatation  of  the  palpebral  fissure  with 
impaired  power  of  closing  the  lid.  Often,  also,  careful 
observation  shows  slight  protrusion  of  the  eye,  and  lack 
of  uniformity  in  the  downward  movement  of  the  lid  and 


BEHAVIOR  OF  PUPIL  AND  ACCOMMODATION.  65 

eyeball.  Those  points  will  enable  one  to  differentiate 
the  spastic  from  the  paretic  variety  of  mydriasis. 

The  characteristic  feature  of  the  latter  condition 
is  absence  of  contraction  of  the  sphincter  muscle,  mani- 
fested especially  by  loss  of  the  light  reflex.  It  presents 
a  moderately  dilated  and  immobile  pupil  in  contrast  to 
the  widely  dilated  and  sensitive  pupil  of  spastic  mydri- 
asis. Another  feature  of  paretic  mydriasis  is  that  it  can 
be  increased  by  atropin,  which,  when  dropped  into  the 
conjunctival  sac,  has  the  two-fold  action  of  paralyzing 
the  terminal  fibres  of  the  third  nerve  and  of  stimulating 
the  sympathetic. 

It  has  been  previously  stated  that  the  light  reflex 
will  be  wanting  when  the  conduction  fails  either  in  the 
optic  or  the  third  nerve,  hence  we  might  subdivide 
paretic  mydriasis  into  (a)  sensory  or  centripetal,  and  (b) 
motor  or  centrifugal  paresis.  With  the  former,  the 
mydriasis  is  always  bilateral  and  associated  with  more 
or  less  loss  of  sight,  so  that  the  visual  perception  is  too 
faint  to  excite  the  motor  impulse.  The  latter  form  is 
usually  associated  with  loss  of  function  of  one  or  more 
of  the  extrinsic  eye  muscles,  and  indicates  an  interrup- 
tion of  the  motor  impulse  at  some  point.  It  may  exist 
with  unimpaired  sight. 

Having  determined  in  a  given  case  which  variety 
of  mydriasis  is  present,  we  are  prepared  to  inquire  next, 
what  deductions  can  logically  be  drawn  therefrom? 


66  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

I.  Spastic  mydriasis  may  aflfect  one  or  both  eyes, 
and  indicates,  as  has  been  mentioned,  an  irritation  of 
the  cilio-spinal  centre  situated  in  the  lower  cervical  and 
upper  dorsal  region  of  the  cord,  or  of  the  cervdcal  sym- 
pathetic.    This  irritation  may  be  direct  or  reflex. 

Direct  irritation  exists  in  the  early  stages  of  all 
inflammatory  diseases  of  the  spinal  cord  and  its  mem- 
branes in  this  locality,  such  as  spinal  congestion,  menin- 
gitis, and  neoplasms,  and  in  the  so-called  "spinal  irrita- 
tion," which  is  frequently  met  with  in  nervous  and 
chlorotic  young  women.  It  is  also  a  premonitory  sign 
of  tabes. 

Reflex  irritation  results  from  irritation  of  the 
skin  (the  so-called  skin  reflex)  already  referred  to.  It 
accompanies  extensive  cutaneous  burns  and  severe  urti- 
caria. Pinching  the  skin  at  the  back  of  the  neck 
causes  mydriasis  in  certain  cases  of  meningitis,  and  is 
known  as  Parrot's  sign.  Intestinal  worms  cause  spastic 
mydriasis  by  reflex  action  ;  also  disease  of  the  apex  of 
the  lung,  and  anuerisms  of  the  aorta  and  arteria  innom- 
mata. 

In  the  latter  cases  the  mydriasis  is  on  the  side 
of  the  lesion.  Cerebral  affections  with  increased  intra- 
cranial pressure,  and  certain  mental  states,  fright,  acute 
mania  and  melancholia,  for  instance,  are,  at  times,  asso- 
ciated with  this  form  of  mydriasis,  the  explanation  of 
which  must  be  a  reflex  irritation  communicated  to  the 
dilating  centre. 


LOSS  OF  THE  LIGHT  REFLEX.  67 

Spastic  mydriasis,  then,  indicates  the  locality  of 
the  casual  affection,  but  furnishes  no  definite  informa- 
tion as  to  its  nature.  Sometimes  dilatation  of  one  pupil 
with  preserved  reaction  to  light,  simulating  spastic 
mydriasis,  is  observed,  which  is  due  to  some  peculiar 
condition  of  the  iris.  Such  a  condition  is  not  of  serious 
import,  and  may  persist  for  years. 

PARETIC    MYDRIASIS.      LOSS  OF  THE    LIGHT  REFLEX. 

As  was  observed  when  discussing  paralysis  of 
the  ocular  muscles,  the  third  nerve  may  be  implicated 
anywhere  between  the  globe  and  its  cortical  termina- 
tion, and  the  same  is  equally  true  of  the  optic  nerve,  so 
that  both  the  motor  and  sensory  varieties  of  paretic 
mydriasis  may  be  advantageously  classified  in  the  same 
manner  that  was  adopted  with  paralysis  of  the  external 
muscles,  namely ;  ist,  Peripheral ;  2d,  Intra-cranial  (a. 
Basilar ;  b.  Nuclear)  ;  3d,  Cortical. 

With  the  first  classification,  that  is,  cases  of  peri- 
pheral origin,  whether  motor  or  sensory,  the  present 
discussion  does  not  concern  itself,  as  they  have  no 
relation  to  the  diagnosis  of  nervous  diseases.  Care 
should  be  taken,  however,  not  to  confound  the  symp- 
toms caused  by  the  use  of  mydriatics,  such  as  atropin, 
duboisine,  cocaine,  hyoscyamine,  etc.,  with  similar  ac- 
companiments of  cerebral  affections.  It  is  important  to 
remember  that  all  drugs  which  dilate  the  pupil  also 
impair  the  power  of  accommodation  and  vice-versa.     The 


68  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

same  is  true  of  myotics  and  spasm  of  the  ciliary  muscle. 

Reflex  iiidoplegia  (it  has  been  previously  stated 
that  the  pupillary  functions  are  usually  reflex)  is  ordi- 
narily bilateral. 

Loss  of  the  light  reflex,  when  monocular,  may 
be  either  peripheral,  basilar  or  nuclear,  and  of  itself 
does  not  furnish  data  for  exact  localization.  It  is 
always  motor.  Otherwise  contraction  would  follow  light 
stimulus  transmitted  from  the  other  eye. 

Monocular  mydriasis  is  sometimes  idiopathic, 
caused  by  exposure  to  cold,  although  in  suspected  dis- 
ease of  the  nerve  centres,  monocular  mydriasis  and  pa- 
ralysis of  accommodation  is  to  be  regarded  with  suspi- 
cion, as  suggesting  the  approach  of  general  paralysis  or 
of  insanity. 

Wernicke's  sign,  or  "  hemianopic  pupillary  inac- 
tion," is  a  trustworthy  guide  in  the  diagnosis  of  the  sit- 
uation of  a  lesion  causing  hemianopic  visual  disorders. 
If  light  thrown  upon  the  blind  portion  of  the  retina 
causes  contraction  of  the  pupils,  it  demonstrates  that 
the  cause  of  the  lesion  is  above  the  reflex  path  for  the 
pupillary  response  to  light  stimulus.  The  converse, 
namely,  lack  of  contraction  of  the  pupils,  is  conclusive 
evidence  that  the  lesion  is  at  the  optic  thalamus,  or  be- 
tween it  and  the  optic  nerve  stem. 

When  hemianopic  pupillary  inaction  exists  with- 
out concomitant  hemianopic  visual  defect,  it  indicates 
that    the    lesion    is   between   the    nucleus    of   the    third 


LOSS  OF  THE  LIGHT  REFLEX.  69 

nerve  and  the  optic  tract.  This  symptom  is  known  as 
Knies'  sign,  and  when  observed  is  of  definite  value  in 
localization. 

In  case  of  sudden  blindness  also  the  presence  or 
absence  of  the  light  reflex  is  of  service  in  determining 
the  location  of  the  lesion  causing  it,  for,  as  we  have 
seen  in  the  case  of  hemianopia,  if  it  is  due  to  a  corti- 
cal disease  affecting  the  higher  centres  beyond  the 
"belt-line,"  so  to  speak,  the  light  reflex  will  be  pre- 
served, while  it  will  be  lost  in  affections  of  the  retina, 
optic  nerve  or  tract.  There  are  exceptions  to  this  rule, 
however,  for  cases  are  on  record  where  there  was  sud- 
den blindness  from  a  lesion  affecting  the  nerve  trunks 
in  front  of  the  chiasm,  in  which  the  pupillary  reflex 
was  preserved.  Such  cases  simply  indicate  that  a 
slighter  stimulus  suffices  for  the  production  of  reflex 
contraction  of  the  constrictor  fibres  of  the  iris,  than  for 
the  perception  of  light. 

An  isolated  paralysis  of  the  constrictor  fibres  of 
the  iris  without  other  signs,  points  to  a  circumscribed 
lesion,  probably  syphilitic,  in  the  anterior  part  of  the 
floor  of  the  fourth  ventricle,  affecting  only  that  part  of 
third  nucleus  from  which  arise  the  fibres  supplying  the 
iris.  It  is  possible  for  such  a  lesion  to  be  manifested 
by  monocular  mydriasis,  but  from  the  anastomosis 
which  exists  between  the  nuclei  of  the  two  sides,  such 
a  condition  is  extremely  unlikely. 


70  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Cortical  paretic  mydriasis  is  bilateral.  It  occurs 
with  cerebral  anemia,  in  apoplexy  and  in  meningeal 
hemorrhage,  and  in  alcoholism.  When  mydriasis  suc- 
ceeds a  primary  myosis  in  apoplexy,  it  is  an  unfavor- 
able symptom,  showing  paralysis  of  the  third  nerv^e 
from  increasing  pressure.  The  presence  of  dilatation  or 
contraction  is  a  valuable  point  of  differential  diagnosis 
between  apoplexy  and  embolism,  as  the  pupils  are  un- 
altered in  the  latter.  It  is  of  frequent  occurrence  dur- 
ing epileptic  seizures,  and  is  associated  with  conditions 
of  increased  intra-cranial  pressure  which  compresses  the 
third  nerve,  such  as  tumors  and  hydrocephalus.  It  fre- 
quently attends  the  later  stages  of  tubercular  meningitis, 
but  is  rare  in  the  epidemic  cerebro-spinal  variety.  This 
fact  may  be  of  value  in  a  differential  diagnosis.  It  oc- 
curs also  in  diseases  of  the  cerebellum.  In  concussion 
of  the  brain  we  find  a  sluggish  action  of  the  pupils 
without  marked  dilatation  or  contraction.  In  coma  from 
compression,  we  find  one  or  both  pupils  dilated  and 
sluggish. 

Care  should  be  exercised  to  discriminate  between 
loss  of  vision  from  cerebral  affections  and  the  indistinct- 
ness resulting  from  impaired  accommodation,  or  because 
of  the  circles  of  diffusion  formed  on  the  retina  in  con- 
sequence of  the  dilated  pupil.  In  the  latter  case,  near 
vision  will  be  restored  by  a  suitable  convex  lens  when 
the  accommodation  is  at  fault,  and  the  circles  of  diffu- 
sion may  be   obviated  by  limiting   the  amount   of   light 


LOSS  OF  THE  LIGHT  REFLEX.  71 

entering  the  eye,  by  looking  through  a  small  opening 
in  a  card  or  similar  device,  thus  improving  vision  for 
all  distances. 

Paretic  mydriasis  is  an  early  symptom  of  general 
paralysis  and  a  late  manifestation  of  paralysis  of  the  in- 
sane. 

Von  Graefe  called  attention  to  an  ephemeral 
variety  of  mydriasis,  which  occurs  transiently,  at  short 
intervals,  and  which  he  regarded  as  a  premonitory 
symptom  of  insanity,  more  especially  of  "ambitious 
monomania."  It  may,  however,  be  of  the  spastic  variety 
due  to  spinal  irritation.  The  pupillary  phenomena  of 
this  disease  will  be  referred  to  again. 

The  condition  of  the  pupil  is  of  service  in  dis- 
tinguishing an  atrophy  of  the  optic  nerve  resulting 
from  inflammation  or  caused  by  cerebral  disease,  from 
that  form  known  as  spinal  atrophy.  In  the  two  former 
cases  it  is,  as  a  rule,  dilated  through  loss  of  the  light 
reflex,  but  in  the  latter  it  is  contracted,  in  consequence 
of  paralysis  of  the  sympathetic. 

Mydriasis  may  be  a  premonition  of  uraemic  in- 
toxication, hence  the  condition  of  the  pupils  should  be 
carefully  watched  in  cases  of  nephritis  when  this  con- 
dition threatens. 

Mydriasis  with  loss  of  power  of  accommodation 
should  awaken  a  suspicion  of  syphilis,  for  Alexander 
states  that   three-fourths  of   such  cases   are   of  syphilitic 


72  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

origin,  while   Uhthoff  estimates  the  proportion   due    to 
this  cause  at  one-fourth  the  whole  number. 

In  cholera,  loss  of  the  light  reflex  is  a  bad  prog- 
nostic omen.  In  the  "  Deuisch.  Med.  IFoc/j."  for  Jan- 
uary 23,  1 89 1,  Corte  states  that  where  the  reaction  to 
light  fails,  a  fatal  tennination  is  certain,  even  in  an  ap- 
parently mild  case,  and,  on  the  other  hand,  the  progno- 
sis is  favorable  even  in  very  severe  cases  if  the  light 
reflex  is  preserved,  and  this  he  considers  true  without 
regard  to  the  existence  of  a  dilated  or  contracted  pupil. 

THE  ARGYLL   ROBERTSON   PUPIL. 

Usually  the  reflex  contraction  of  the  iris  attending 
efforts  of  accommodation  and  convergence  is  lost  simul- 
taneously with  failure  of  the  light  reflex.  It  is  possible 
for  the  associated  contraction  to  be  preserved  when 
there  is  no  response  to  the  stimulus  of  light,  and  this 
variety  of  reflex  iridoplegia  is  known  as  the  "  Argyll 
Robertson  pupil,"  and  is  a  very  valuable  diagnostic  in- 
dication in  two  forms  of  nervous  disease. 

The  method  of  testing  the  accommodative  and 
convergent  reaction  has  already  been  mentioned  on  page 
59,  and  need  not  be  repeated  here.  Noyes  maintains 
that  convergence  and  not  accommodation  is  the  factor 
inducing  contraction  in  the  Robertson  pupil,  and  sup- 
ports his  statement  by  eliminating  all  accommodation. 
This  he  did  by  placing  a  strong  concave  lens  before  the 
patient's  eye  during  the   examination,  and  found  the  re- 


THE  ARGYLL  ROBERTSON  PUPIL.  73 

suit  to  be  the  same.  ("  Diseases  of  the  Eye,"  last  edi- 
tion, page  436). 

The  pupil  may  be  of  normal  size,  dilated  or  con- 
tracted, but  usually  there  is  more  or  less  myosis.  For 
this  reason  it  would  seem  that  a  consideration  of  this 
pupillary  condition  in  connection  with  mydriasis,  was 
inappropriate.  But  inasmuch  as  the  myosis  is  only  an 
association,  and  not  an  essential  feature  of  the  "  Argyll 
Robertson  pupil,"  and  since  the  characteristic  of  the 
latter  is  a  paresis  of  the  sphincter  iridis,  it  seems  advis- 
able to  discuss  it  here. 

Its  presence  demonstrates  a  lesion  affecting  the 
fibres  extending  from  the  tubercula  quadrigemina  to 
the  third  nucleus.  Since  there  is  no  impairment  of 
vision  and  no  loss  of  voluntary  motion,  it  is  evident 
that  the  primary  optic  ganglia  and  the  third  nucleus 
are  unaffected.  It  is  found  in  locomotor  ataxia,  or  tabes 
dorsalis,  and  paresis,  or  progressive  paralysis  of  the  in- 
sane, as  a  characteristic  symptom  and  is  very  rare  in 
other  diseases.  Hence  it  becomes  a  very  valuable  aid 
in  diagnosis,  especially  as  it  often  occurs  very  early  in 
these  two  affections.  The  peculiar  mental  condition 
and  the  disorder  of  speech  in  paresis  will  enable  one  to 
make  a  differential  diagnosis.  These  two  diseases  may 
exist  simultaneously. 

Dillman  says  that  the  "  Argyll  Robertson  pupil " 
is  found  in  70  per  cent,  of  the  cases  of  tabes,  and  in  25 


74  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

per  cent,  it   is  a   very  early  symptom.      It   is   estimated 
that  this  symptom  occurs  in  half  the  cases  of  paresis. 

MYOSIS. 

With  myosis  also  we  recognize  a  spastic  and  a 
paretic  variety.  The  former  is  the  expresssion  of  irrita- 
tion of  the  oculo-motor  nerve,  and  is  accompanied  by 
spasm  of  accommodation.  Atropia  will  cause  full  dila- 
tation and  relaxation  of  accommodation.  It  commonly 
attends  hyperaemia  of  the  brain  and  the  early  inflam- 
matory period  of  cerebral  affections,  and  of  tubercular 
and  cerebro-spinal  meningitis,  the  irritable  premonitory 
stage  of  apoplexy  and  of  nacrosis,  and  the  excitement  of 
intoxication  from  alcohol  and  chloroform. 

We  find  it  with  hemorrhage  into  the  cerebral 
ventricles  and  into  the  pons  Varolii,  in  which  situations 
an  irritation  of  the  adjacent  oculo-motor  nucleus  results. 
A  neoplasm  near  the  origin  or  along  the  course  of  the 
third  nerve,  would,  in  its  early  stages,  cause  spastic 
myosis,  and  it  accompanies  hysterical  and  epileptic  at- 
tacks. It  may  be  due  to  the  influence  of  nicotine,  and 
it  occurs  in  reflex  irritation  from  affections  of  the  fifth 
nerve. 

PARETIC   MYOSIS. 

The  paretic  is  a  much  more  common  form  of 
myosis,  and  is  characterized  by  failure  of  the  skin  re- 
flex, and,  when   uncomplicated,  the  pupil  is  of   medium 


PARETIC  MYOSIS.  75 

size  and  responds  both  to  light  and  convergence.  It  is 
an  evidence  of  paralysis  of  the  sympathetic,  which  may 
be  due  to  direct  injury  of  the  cervical  sympathetic,  or  to 
its  compression  by  an  anuerism,  a  tumor,  enlarged  glands, 
etc.  It  is  then  monocular  and  is  associated  with  other 
evidences  of  sympathetic  paralysis,  such  as  slight  ptosis 
and  flushing  of  the  corresponding  side  of  the  face,  with 
local  increase  of  temperature  amounting  sometimes  to 
1.5°  F.,  measured  in  the  nostril  or  external  auditory 
canal.     Such  a  condition   may  last  for  years. 

Paretic  myosis  is  generally  caused  by  a  chronic 
disease  of  the  spinal  cord.  It  does  not  occur,  however, 
when  the  disease  is  situated  below  the  upper  dorsal  re- 
gion. In  this  variety  of  myosis,  both  pupils  are  affected, 
the  accommodation  is  normal,  and  the  pupil  can  be 
dilated  with  atropin,  although  rather  feebly.  Atropin 
has  a  two-fold  action  in  producing  dilatation.  It  causes 
paralysis  of  the  terminal  fibres  of  the  third  nerve  dis- 
tributed to  the  sphincter-pupillae  and  ciliary  muscle,  and 
at  the  same  time  it  stimulates  the  sympathetic  which  in- 
nervates the  dilator  fibres.  This  explains  the  more  en- 
ergetic action  of  the  drug  in  spasmodic  than  in  the 
paretic  form  of  myosis.  The  latter  is  more  especially 
met  with  in  tabes  and  progressive  paralysis  of  the  in- 
sane. Dillman  says  that  it  is  present  in  23  per  cent,  of 
the  cases  of  tabes. 

We  have  seen  that  in  these  two  diseases  the 
"Argyll    Robertson    pupil "    is    also    usually  present,    so 


76  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

that  we  find  the  characteristic  feature  to  be  that  of  re- 
flex iridoplegia  in  the  full  meaning  of  the  term,  that 
is,  a  failure  of  all  pupillary  reflexes,  and  this  condition 
serves  as  a  valuable  point  in  differential  diagnosis  be- 
tween true  tabes  and  the  multiple  neuritis  (of  alcoholic 
origin,  usually)  which  so  closely  simulates  it,  for  in  the 
latter  there  is  an  absence  of  myosis  and  reflex  irido- 
plegia. 

In  tabes,  the  reaction  to  light  generally  fails 
first.  Knies  says :  "Absence  of  pupillary  reaction  to 
light,  which  is  followed  by  loss  of  reaction  to  accom- 
modation and  to  convergence  and  to  cutaneous  irritants, 
is  one  of  the  most  characteristic  signs  of  impending  or 
beginning  tabes,  and  forms  an  integral  part  of  the  fur- 
ther clinical  history  of  the  disease." 

"  The  presence  of  oculo-pupillary  and  vaso-motor 
symptoms  of  paresis  or  irritation  are  important  in  an 
accurate  local  diagnosis  in  injuries  of  the  spine.  Almost 
every  severe  spinal  injury  is  attended  with  vaso-motor 
paralysis  and  rise  of  temperature  upon  the  side  of  the 
motor  paralysis." 

The  presence  of  myosis  and  iridoplegia  with 
coma  of  syphilitic  origin,  enables  us  to  differentiate  it 
from  a  similar  condition  due  to  uraemia  or  alcoholism 
in  which  there  is  mydriasis.  It  is  hardly  necessary  to 
mention  the  extreme  myosis  which  occurs  in  opium 
poisoning.  The  absence  of  myosis  would  be  a  counter- 
indication     in     suspected     acute     poisoning,    but    it     is 


ANISOCOREA.  77 

worthy  of   remark   that   mydriasis   is   not  uncommon  in 
chronic  opium  habitues. 

ANISOCOREA. 

By  this  term  is  understood  an  inequality  in  the 
size  of  the  two  pupils,  or  an  irregular  and  unequal  re- 
sponse to  the  various  stimuli. 

Knies  says  that  difiference  in  size  of  the  pupils 
points  to  the.  path  between  the  optic  ganglia  and 
the  nuclei  of  the  third  nerve,  as  the  location  of  the  le- 
sion causing  it.  "  It  may  be  an  irritative  lesion  or  a 
commencing  paralysis,  according  as  one  pupil  is  too 
small  or  too  large.  The  one  which  reacts  most  freely 
and  readily  to  light,  convergence,  etc.,  is  to  be  consid- 
ered the  normal  one." 

Dillman  says  that  this  condition  occurs  in  34  per 
cent,  of  the  cases  of  tabes,  and  therefore  it  furnishes 
still  another  oculo-pupillary  sign  of  that  disease  in  addi- 
tion to  those  already  mentioned.  In  common  with  my- 
osis  and  reflex  iridoplegia,  anisocorea  is  characteristic 
also  of  the  early  stage  of  general  paralysis  of  the  in- 
sane. 

Oliver,  of  Philadelphia,  in  discussing  the  pupill- 
ary phenomena  met  with  in  this  disease  (in  the  "  Med. 
News"  of  November  ii,  1893),  mentions  "Irregularities 
in  size  and  reaction  of  the  pupils  with  myosis.  Dimin- 
ished action  of  mydriatics,  marked  temporary  asymmet- 
ries, one  pupil  being   quite   small  and  irregular  for  sev- 


78  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

eral  examinations,  while  its  fellow  was  large  and  ovoid 
or  oval." 

HIPPUS. 

There  is  a  condition  of  the  iris  known  as  "  hip- 
pus,"  characterized  by  alternate  contraction  and  dilata- 
tion of  the  pupil,  which  often  accompanies  nystagmus, 
and  is  of  similar  significance.  It  must  not  be  con- 
founded with  that  tremor  of  the  iris  that  accompanies 
movements  of  the  eye  in  dislocation  or  absence  of  the 
lens.  Hippus  occurs  frequently  in  multiple  sclerosis, 
and  in  connection  with  hysterical  and  epileptic  seizures. 

Rhythmical  contractions  of  the  iris  have  been 
noticed  in  typhoid  fever  during  the  stage  of  cerebral 
manifestations. 

"  Rapid  alteration  of  myosis  and  mydriasis  has 
also  been  observed  in  tubercular  meningitis."  (Knies). 

DISORDERS   OF   ACCOMMODATION. 

The  ciliary  muscle  and  the  iris,  being  both  in- 
nervated by  the  third  nerve,  usually  act  together.  Spasm 
of  accommodation,  as  a  rule,  is  accompanied  with  myo- 
sis, and  paralysis  of  accommodation  with  mydriasis. 
Remembering,  however,  that  the  fibres  which  supply  the 
ciliary  muscle  arise  from  a  separate  nucleus,  we  can  un- 
derstand how  the  accommodation  may  be  lost  alone  by  a 
circumscribed  nuclear  lesion  in  the  vicinity  of  the  floor 
of  the  fourth  ventricle  (the  aqueduct).  Loss  of  accom- 
modation  (associated  or  not  with  mydriasis,  or  paralysis 


DISORDERS  OF  ACCOMMODATION.  79 

of  the  extrinsic  eye  muscles)  is  the  most  frequent  form 
of  post-diphtheritic  paralysis,  which  is  generally  of  nu- 
clear origin,  though  sometimes  it  is  due  to  a  peripheral 
neuritis.  This  is  frequently  the  only  manifestation  of 
post-diphtheritic  paralysis,  and  readily  yields  to  appro- 
priate treatment,  while,  if  unrecognized,  it  may  seriously  • 
alarm  both  physician  and  patient.  It  may  occur  very 
soon  or  at  a  considerable  time  after  disappearance  of 
the  throat  symptoms.  It  affects  both  eyes  and  occurs  more 
often  in  children  than  in  adults.  Frequently  the  pupil  is 
unaffected.  It  may  be  a  valuable  diagnostic  indication  in 
doubtful  cases,  for  the  presence  of  paralysis  of  accommo- 
dation following  a  sore  throat  or  a  membranous  inflamma- 
tion of  the  conjunctiva,  of  the  vulva,  or  on  a  wound,  de- 
cides definitely  the  diphtheritic  nature  of  the  case.  Bilat- 
eral cycloplegia,  as  an  isolated  symptom,  occurs  also  in 
certain  diseases  of  the  cord,  and  may  be  explained  by 
an  extension  upward  of  the  disease  to  the  third  nucleus. 
Noyes  enumerates  the  following  diseases  which 
may  be  complicated  with  paralysis,  more  or  less  com- 
plete, of  the  faculty  of  adjustment  of  near  vision,  viz.  : 
diabetes,  trichinosis,  cerebro-spinal  sclerosis,  essential 
anaemia,  masturbation  and  excessive  venery,  alcoholism, 
uterine  and  syphilitic  affections,  neuralgia  of  the  dental 
and  other  branches  of  the  fifth  nerve.  While  of  no  spe- 
cial value  as  a  means  of  diagnosis  in  these  affections,  a 
recognition  of  the  cause  of  the  visual  disorder  is  desir- 
able, as  influencing  the  treatment. 


CHAPTER  IV. 

THE   OPHTHALMOSCOPIC    APPEARANCES    OF    THE    FUNDUS 

OCULI,    INCLUDING    AFFECTIONS  OF  THE  CHOROID, 

RETINA   AND  OPTIC   NERVE. 

For  the  diagnosis  of  pathological  changes  in  the 
interior  of  the  eye,  behind  the  crystalline  lens,  the  aid 
of  the  ophthalmoscope  is  necessary.  This  instrument  is 
of  very  great  value  in  the  diagnosis  of  cerebral  and 
spinal  affections,  as  well  as  of  certain  constitutional  dis- 
orders, and  every  progressive  physician  should  be  famil- 
iar with  its  use.  The  instrument  consists  essentially  of 
a  mirror  perforated  in  its  centre,  and  having  a  series 
of  lenses,  any  one  of  which  can  be  brought  directly 
behind  the  perforation.  The  pupil  of  the  patient  is 
illuminated  by  light  reflected  from  a  gas  jet  by  the  mir- 
ror, and  on  looking  through  the  aperture,  directly  in 
the  line  of  the  illuminating  rays,  the  observer  is  en- 
abled to  examine  the  interior  of  the  patient's  eye.  Many 
different  patterns  of  the  instrument  are  to  be  obtained, 
but  for  the  use  of  the  general  practitioner  there  is 
none  better  than  Loring's  Student's  Ophthalmoscope,  a 
cut  of  which  is  given   below. 

The  optic  nerve  is  but  an  off-shoot  from  the 
brain,  and  the  retina  but  an  expansion  of  the  former,  so 

(80) 


AFFECTIONS  OF  THE  RETINA  AND  OPTIC  NERVE.  81 

that  we  have  here  a  continuit)^  of  nervous  structure  sub- 
ject to  identical  morbid  processes.  Moreover,  the  optic 
nerve  sheaths  enter  into  the  structure  of  the  tunics  of 
the  eyeballs   on  the  one  side,  and   are   continuous  with 


the  cerebral  meninges  on  the  other ;  and  the  sub-vagi- 
nal spaces  are  tubular  prolongations  of  the  cranial  sub- 
arachnoid and  sub-dural  spaces.  It  is  easy  to  under- 
stand, therefore,  how  meningitis  may  be  complicated 
with  peri-  or  insterstitial  neuritis,  and  how  watery  or 
purulent  exudations  in  the  cranial  cavity  may  cause  dis- 
tention of  the  nerve  sheaths  and  induce  inflammatory 
changes  in  the  papilla  and  retina.  Again,  derangement 
of  the  cerebral  circulation  is  accompanied  with  simulta- 
neous changes  in  the  retinal  vessels,  and  the  ophthal- 
moscope enables  one  to  recognize  hyperaemia  and  anae- 
mia of  the  retina,  hemorrhage,  embolism  of  the  arteria 
centralis,  and  the  varieties  of  intra-ocular  inflammation 
which  are  symptomatic  of  constitutional  affections.  Fre- 
quently before  the  sight  begins  to  suffer,  the  ophthal- 
'6 


82  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

raoscope  reveals  changes  at  the  optic  disc,  and  in  a 
doubtful  case  we  are  often  enabled  by  its  aid  to  con- 
firm a  diagnosis  of  disease  of  the  brain,  heart,  kidneys, 
etc.,  and  to  interpret  the  true  meaning  of  various  ner- 
vous symptoms  not  otherwise  of  definite  signification. 

In  these  pages  it  is  not  my  intention  to  discuss 
the  differential  diagnosis  of  the  various  forms  of  disease 
at  the  fundus  of  the  eye.  Such  a  diagnosis  requires 
special  training  and  skill  not  possessed  by  the  majority 
of  general  practitioners.  In  pursuing  the  general  plan 
of  this  treatise,  I  shall  endeavor  simply  to  point  out  the 
significance  of  certain  pathological  conditions  as  deter- 
mined by  ophthalmoscopic  examination,  assuming  the 
reader  to  be  familiar  with  the  use  of  the  instrument,  or 
that,  not  possessing  the  requisite  skill  and  knowledge, 
he  appreciates  the  importance  and  value  of  such  a  pro- 
cedure, and  will  call  in  the  aid  of  a  specialist. 

AFFECTIONS  OF  THE  CHOROID. 

As  with  iritis,  so  also  with  choroiditis,  the  most 
frequent  cause  is  syphilis,  so  that  the  presence  of  either 
the  diffuse  or  the  disseminate  variety  awakens  a  strong 
suspicion  of  a  specific  origin,  but  there  are  no  charac- 
teristic features  which  warrant  an  absolute  diagnosis  of 
syphilis.  It  occurs  in  both  the  acquired  and  the  inher- 
ited form  of  the  disease,  but  is  most  often  met  with 
in  the  second,  third  or  fourth  years  of  the  acquired 
form.      When   syphilis  can  be   excluded  as   the  exciting 


AFFECTIONS  OF  THE  CHOROID.  83 

cause,  disorders  of  nutrition,  such  as   anaemia,  chlorosis 
and  scrofula,  are  to  be  sought  for. 

We  also  recognize  a  metastatic  suppurative  cho- 
roiditis, which  is  a  manifestation  of  pyaemia,  and  occurs 
most  frequently  as  a  complication  of  puerperal  fever.  It 
may  be  the  first  or  the  only  indication  of  pyaemia,  and 
hence  may  lead  to  the  recognition  of  a  hitherto  unsus- 
pected suppurative  condition. 

Knies  says  that  a  "  sero-plastic  purulent "  cho- 
roiditis occurs  frequently  as  a  complication  or  a  sequence 
of  cerebral  meningitis,  especially  in  children.  In  such 
cases  it  is  usually  monocular,  and  caused  primarily  by 
phlebitis  of  the  ophthalmic  vein,  although  there  may  be 
"a  coincident  deposit  of  morbific  material  in  the  pia 
mater  and  the  choroid." 

A  septic  choroiditis  has  been  noticed  after  ty- 
phoid and  intermittent  fevers.  Tuberculosis  of  the  cho- 
roid occurs  with  or  without  tubercular  meningitis  in  the 
form  of  "  single  or  multiple  whitish  yellow  or  rosy  yel- 
low round  masses  over  which  the  retinal  vessels  pass. 
Their  outlines  are  rather  hazy.  They  are  very  rarely 
surrounded  by  a  striking  pigmented  zone,  and  this  is 
important  in  making  a  differential  diagnosis.  The  indi- 
vidual nodules  usually  grow,  coalesce  and  project  more 
and  more  into  the  vitreous.  Usually  they  belong  to  the 
terminal  stage  of  tuberculosis,  and  develop  shortly  be- 
fore death."  Therefore  they  possess  but  little  diagnostic 
value  as  a   rule,  but  their   recognition  is   important,  be- 


84  THE   EYE   AS   AN   AID   IN   GENERAL  DIAGNOSIS. 

cause  sometimes,  as  Hangg  says  in  "  Dis.  Strasbourg^^^ 
1890,  "they  may  apparently  constitute  the  sole  manifes- 
tation of  tuberculosis  for  a  long  time." 

AFFECTIONS  OF  THE   RETINA    AND   OPTIC   NERVE. 

We  can  draw  no  fast  lines  of  differentiation  be- 
tween the  diagnostic  significance  of  neuritis  and  retinitis, 
as  they  so  frequently  coexist  and  merge  the  one  into 
the  other.  In  general  terms  it  may  be  stated  that  in 
constitutional  disorders  pathological  changes  are  more 
pronounced  in  the  tissues  of  the  retina,  while  the  intra- 
ocular extremity  of  the  optic  nerve  is  first  and  most 
predominantly  affected  by  intra-cranial  and  spinal  affec- 
tions. It  is  deemed  advisable,  therefore,  to  consider  sep- 
arately the  ophthalmoscopic  appearances  of  the  back 
ground  of  the  eye  as  they  relate  to  systemic  and  ner- 
vous diseases,  and  first  let  us  inquire  what  data  may 
thus  be  obtained  for  the  diagnosis  of  constitutional  dis- 
eases and  those  of  remote  organs. 

Retinitis  and  neuro-retinitis  are  found  in  connec- 
tion with  many  and  diverse  constitutional  disorders. 
Often  they  are  of  no  special  diagnostic  importance,  oc- 
curring simply  as  complications  in  the  course  of  well 
pronounced  and  universally  recognized  diseases.  As  ex- 
amples may  be  mentioned  their  occurrence  in  typhus 
and  typhoid  fever,  measles,  small-pox,  diphtheria,  pneu- 
monia and  intermittent  fever ;  in  disturbances  of  nutri- 
tion such  as  scrofula,  scurvy,  purpura  and  oxaluria,  and 


CHANGES  IN  THE  CIRCULATION  OP  THE  RETINA.  85 

in  acute  anaemia,  especially  after  hemorrhage  from  the 
uterus  or  stomach.  Sometimes  they  occur  as  a  rheu- 
matic manifestation  and  in  menstrual  disturbances. 

In  other  instances,  affections  of  the  optic  nerve 
and  retina  are  of  great  value  in  the  diagnosis  of  consti- 
tutional maladies  and  disorders  of  remote  organs.  In 
general,  it  may  be  stated  that  morbid  appearances  in 
these  tissues,  when  not  connected  with  nervous  diseases, 
or  indicative  of  them,  point  to  lesions  of  the  heart  and 
blood  vessels,  to  syphilis  or  to  renal  disease. 

CHANGES  IN   THE  CIRCULATION   OF  THE   RETINA. 

Venous  hyperaemia  of  the  retina  accompanies 
cardiac  affections  in  which  the  return  of  the  blood  to- 
ward the  heart  is  impeded,  as  in  valvular  lesions  and  in 
fatty  heart.  Associated  with  the  above,  there  may  be 
pulsation  of  the  retinal  arteries.  This  association  of 
arterial  pulsation  and  fulness  of  the  retinal  veins  almost 
always  exists  in  aortic  insufficiency.  The  explanation  of 
the  former  consists  in  a  hypertrophy  of  the  left  ventri- 
cle, whereby  the  blood  pressure  is  increased  during  its 
contraction,  and  the  venous  hyperaemia  results  from  the 
regurgitation  which  accompanies  the  ventricular  diastole. 
The  same  conditions  also  explain  the  alternate  redden- 
ing and  pallor  of  the  disc  observed  in  aortic  insuffi- 
ciency. Retinal  pulsation  sometimes  occurs  with  aneu- 
rism of  the  aorta  and  arteria  innominata. 


86  THE   EYE  AS   AN  AID  IN  GENERAL  DIAGNOSIS. 

An  embolism  of  the  central  retinal  artery  may 
be  the  first  indication  of  an  insidious  endocarditis,  as 
was  the  case  in  a  patient  of  the  writer.  Thus  the  oph- 
thalmoscope may  afford  the  first  evidence  of  heart  dis- 
ease, and  aid  in  the  differential  diagnosis  of  its  varied 
forms. 

Hemorrhage  into  the  retina,  without  accompany- 
ing inflammation,  indicates  (a)  increased  blood  pressure, 
such  as  occurs  in  hypertrophy  of  the  heart,  and  in  val- 
vular lesions  and  in  suppresio  mensuum  ;  (b)  disease  of 
the    retinal    vessels ;    (c)  morbid    states  of  the   blood. 

Arterio-sclerosis  and  an  atheromatous  condition  of 
the  retinal  arteries  not  infrequently  cause  hemorrhage. 
With  the  ophthalmoscope  the  arteries  appear  narrower 
than  usual,  and  this  narrowing  is  often  more  con- 
spicuous at  certain  portions  of  the  vessel,  giving  it 
an  irregular  wavy  outline.  These  changes  are  more 
marked  in  the  region  of  the  macula,  because  the  nutri- 
tion of  this  part  of  the  retina  is  not  equal  to  that  of 
the  other  portions.  Such  a  condition  of  the  retinal  ves- 
sels is  of  importance  as  an  indication  of  a  similar  con- 
dition existing  in  other  portions  of  the  body,  especially 
in  the  brain.  When  observed,  with  or  without  retinal 
hemorrhages,  it  is  a  warning  signal  of  impending  cere- 
bral apoplexy,  and  should  lead  the  physician  to  adopt 
precautionary  measures  to  prevent  such  a  catastrophy. 

Such  vascular  degeneration  often  results  from 
syphilis.      It   is    frequent   with   renal    affections,   and   it 


CHANGES  IN  THE  CIRCULATION  OF  THE  RETINA.  87 

should  also  arouse  a  suspicion  of  diabetes,  for  retinal 
hemorrhages  due  to  vascular  degeneration  are  not  infre- 
quent in  this  condition.  They  appear,  as  a  rule,  in  the 
form  of  small,  roundish  spots  (not  striated).  Hirshberg 
says  they  always  occur  when  the  disease  has  lasted  more 
than  ten  or  twelve  years,  and  he  regards  them  as  of 
unfavorable  prognostic  significance.  The  association  of 
nephritis  with  the  late  stages  of  the  diabetes  should  not 
be  forgotten,  and  the  possibility  of  the  dependence  of 
the  retinal  hemorrhages  upon  the  latter.  With  nephritis 
the  hemorrhages  are  more  frequently  striated. 

Retinal  hemorrhages,  due  to  a  diseased  condition 
of  the  blood,  occur  in  infectious  diseases,  in  pyaemia 
and  septicaemia,  in  profound  anaemia,  in  malaria,  in  ex- 
tensive burns  of  the  skin,  in  poisoning  by  phosphorus 
and  lead,  and  after  the  bites  of  venomous  snakes.  Some 
of  these  varieties  of  hemorrhage  demand  special  consid- 
eration. 

While  the  diagnosis  of  infectious  diseases  is  not 
in  any  degree  dependent  upon  the  existence  of  reti- 
nal hemorrhages,  they  are  not  of  infrequent  occurrence, 
and  are  of  prognostic  importance.  They  may  occur  at 
all  stages,  and  are  an  unfavorable  complication,  espe- 
cially where  occurring  early,  indicating,  as  they  do,  a 
condition  of  "profound  toxaemia."  The  same  may  be 
said  of  pyaemia  and  septicaemia.  When  they  occur 
early  in  acute  septicaemia,  a  fatal  termination  may  be 
expected  within  a  very  few  days.    When  they  are  .found 


88  THE   EYE   AS   AN   AID   IN  GENERAL  DIAGNOSIS. 

after  cutaneous  bums,  they  indicate  a  condition  similar 
to  septicaemia,  resulting  from  the  absorption  of  decom- 
posing material. 

The  presence  of  retinal  hemorrhages  affords  valu- 
able evidence  in  the  differential  diagnosis  between  chlo- 
rosis and  pernicious  anaemia,  for  they  frequently  occur 
with  the  latter,  but  never  in  pure  chlorosis.  The 
hemorrhages  are  unaccompanied  with  retinitis,  and  have 
frequently  a  grayish  red  centre  which  is  considered 
quite  characteristic.  The  fact  that  retinal  hemorrhages 
rarely  occur  in  cachectic  conditions  resembling  anaemia 
is  another  useful  diagnostic  point,  and  emphasizes  the 
importance  of  ophthalmoscopic  examinations  in  the  dif- 
ferential diagnosis  of  such  conditions,  especially  in  se- 
vere and  chronic  cases. 

Hemorrhages  very  frequently  attend  the  various 
forms  of  retinitis  in  which  they  form  an  integral  factor, 
and  to  which  we  will  next  devote  our  attention.  For 
the  purpose  of  general  diagnosis  we  recognize  the  fol- 
lowing varieties  of  retinitis,  viz.  : 

1.  Retinitis  albuminurica  or  nephritica,  accom- 
panying different  varieties  of  renal  disease,  including 
the  retinitis  albuminurica  of  pregnancy. 

2.  Retinitis  syphilitica. 

3.  Retinitis  diabetica. 

4.  Retinitis  leukaemica. 

5.  Retinitis  of  gouty  origin. 

.    With   all   varieties  the   optic  nerve    is,  as  a  rule. 


CHANGES  IN  THE  CIRCULATION  OP  THE  RETINA.  89 

involved  to  a  greater  or  less  degree,  so  that  the  desig- 
nation neuro-retinitis  would  define  the  condition  more 
accurately. 

As  previously  remarked,  the  differential  diagnosis 
of  these  varieties  of  retinitis  requires  expert  skill  and 
experience,  and  is  beyond  the  scope  of  this  work.  The 
reader  is  referred  to  treatises  upon  ophthalmology  for 
such  discussions.  The  features  common  to  all  varieties, 
but  differing  in  degree  and  in  distribution,  are  changes 
in  the  retinal  vessels,  congestion,  haziness  and  indis- 
tinctness of  the  outlines  of  the  optic  disc,  hemorrhages 
and  exudation  (serous  or  plastic)  into  the  retina,  sclero- 
sis and  fatty  degeneration  of  the  vascular  and  nervous 
elements,  and  hyperplasia  of  the  connective  tissue.  The 
stellate  appearance  of  the  exudation  distributed  around 
the  macular  region  in  the  early  stages  of  the  disease  is 
quite  characteristic  of  the  nephritic  variety  of  retinitis, 
although  it  is,  at  times,  closely  simulated  by  the  dia- 
betic, anaemic  and  leukaemic  retinitis.  Thus,  while 
there  are  special  features  which  are  more  frequently 
found  in  certain  special  varieties  of  retinitis,  there  is  no 
variety  which  is  absolutely  pathognomonic.  It  is  the 
presence  of  retinitis  or  neuro-retinitis  in  one  of  its 
phases,  rather  than  the  special  and  peculiar  features 
which  it  presents,  that  is  of  special  importance  to  the 
general  practitioner. 

Retinitis    occurs   most    often   in    connection   with 
albuminuria,  next  with   syphilis,  and   diabetes  is  consid- 


90  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

ered  the  third   most   frequent  cause.     We  will   consider 
these  associations  in  the  order  enumerated : 

THE   RELATION   OF   RETINITIS   AND    NEURORETINITIS  TO 
ALBUMINURIA. 

The  ophthalmoscope  affords  very  great  assistance 
in  the  diagnosis  of  nephritis.  Every  oculist  of  experi- 
ence is  familiar  with  the  fact  that  retinitis  albuminu- 
rica  is  often  one  of  the  earliest  symptoms  of  inflamma- 
tion of  the  kidneys.  Failure  of  vision,  without  apparent 
cause,  should  lead  without  delay  to  an  ophthalmoscopic 
examination,  which  may  disclose  the  evidence  of  nephri- 
tis, or,  in  a  doubtful  case,  such  an  examination,  even 
before  there  is  any  impairment  of  vision,  may  demon- 
strate the  cause  of  constitutional  symptoms,  which  pre- 
viously had  not  been  rightly  interpreted. 

It  has  been  variously  estimated  that  from  20-33 
per  cent,  of  all  cases  of  nephritis  are  associated  with 
retinitis.  It  occurs  with  various  forms  of  chronic  kid- 
ney disease,  but  most  frequently  with  the  contracted  or 
atrophic  kidney.  It  is  rare  in  the  waxy  form  and  in 
the  large  white  kidney.  Next  in  frequency  is  the  ne- 
phritis of  pregnancy,  and  last  the  post-scarlatinal  va- 
riety. 

Chronic  nephritis  in  all  forms  is  a  serious  maU 
ady,  coming  on  gradually  and  insidiously.  When  in  an 
advanced  stage  it  is  beyond  the  curative  reach  of  medi- 
cal   skill,  although    much   may  be   done  to  prolong  life 


RELATION  OF  RETINITIS,  ETC.  91 

and  to  mitigate  suflfering.  In  its  early  stages  it  can  fre- 
quently be  arrested  and  sometimes  radically  cured.  No 
aids  to  diagnosis  are  to  be  neglected  in  these  conditions, 
and  no  warning  eye  symptom  should  be  misunderstood 
or  disregarded,  and  I  cannot  too  strongly  emphasize  the 
fact  that  there  are  changes  in  the  background  of  the 
eye,  which  are  almost  pathognomonic  of  disease  of  the 
kidneys,  and  there  are  others  which  are  highly  suggest- 
ive of  such  conditions. 

Usually,  both  eyes  are  affected,  but  often  in  varying 
degrees.  Marple,  in  the  "  N.  Y.  Med.  Record  "  for  March 
II,  1893,  remarks  that  "According  to  the  testimony  of 
most  observers,  unilateral  neuro-retinitis  of  Bright's  dis- 
ease, even  where  it  remains  unilateral  for  only  a  short 
time,  is  of  rare  occurrence.  Cases  which  remain  for 
month  or  years  with  only  one  eye  involved  are  exces- 
sively rare.  When  the  affection  comes  on  in  a  few 
hours,  as  after  an  injury,  or  remains  limited  to  one  eye 
for  months  or  years,  as  in  chronic  renal  disease,  the  or- 
dinarily accepted  theories  as  to  its  causation  seem  inade- 
quate. A  satisfactory  explanation  of  such  cases  seems 
difficult  if  not  impossible." 

The  ophthalmoscopic  appearances  bear  no  definite 
ratio  to  the  degree  of  impairment  of  vision,  for  preser- 
vation of  useful  sight  is  not  incompatible  with  pro- 
nounced changes  in  the  retina.  It  is  rare  that  com- 
plete blindness  results. 

The    existence    of   retinitis    is    not    only  of    diag- 


92  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

nostic,  but  of  prognostic  importance  with  renal  affec- 
tions. The  eye  complication  may  recover,  while  the 
nephritis  continues.  It  has  been  stated  upon  good 
authority  that  "  life  is  rarely  prolonged  more  than  one, 
or,  at  most,  more  than  two,  years,"  after  the  develop- 
ment of  retinitis. 

Bull  gives  in  the  "Trans.  Am.  Oph.  So.,"  a  re- 
port of  the  history  of  103  cases  of  chronic  renal  disease 
with  retinitis.  Of  these  more  than  50  per  cent,  died 
during  the  first  year,  and  the  majority  within  six 
months;    17  per  cent,  died  during  the  second  year. 

Those  cases  associated  with  retinal  hemorrhages 
are  more  unfavorable  than  those  without.  It  has  been 
remarked  that  the  ophthalmoscopic  appearances  which 
are  so  frequently  found  with  renal  affections  as  to  con- 
stitute a  distinct  variety,  designated  as  retinitis  albumi- 
nurica,  are  also  occasionally  found  in  diabetes  and  leu- 
kaemia and  pernicious  anaemia.  They  may  be  present 
without  any  assignable  cause.  Nevertheless,  the  ab- 
sence of  albuminuria  must  not  be  allowed  without 
repeated  and  careful  examinations. 

RETINITIS  ALBUMINURICA   OF   PREGNANCY. 

Retinitis  has  been  observed  as  early  as  the  third 
month,  but  it  is  more  frequent  in  the  later  stages — the 
seventh  or  eighth  month — and  more  often  in  primparae. 
Since,  as  has  already  been  remarked,  vision  is  not  al- 
ways affected  early  in  the  disease,  systematic  ophthalmo- 


RETINITIS  ALBUMINURICA  OF  PREGNANCY.  93 

scopic  examinations  should  be  made  during  pregnancy 
whenever  albuminuria  exists. 

The  principal  interest  which  attaches  to  it  is  as 
regards  the  question  of  the  advisability  of  the  induction 
of  premature  labor.  Howe,  Pooley  and  Moore  have  re- 
ported cases  where  this  procedure  restored  the  sight. 

Howe  says  ("Amer.  Journal  Ophthal.,"  Vol.  II,  pp. 
5,  6,  1885),  "  The  induction  of  labor  is  warrantable 
where  retinitis  occurs  in  the  earl}'-  stage  of  pregnancy, 
and  persists  in  spite  of  proper  treatment,  but  is  not  war- 
rantable in  the  last  few  weeks,  in  spite  of  the  greater 
ease  with  which  it  is  accomplished." 

Randolph,  of  Baltimore,  concludes  from  his  per- 
sonal experience  that  "visual  disturbances  showing 
themselves  in  the  last  seven  weeks  of  pregnancy,  while 
indicating  the  same  retinal  lesion,  are  of  less  grave  im- 
port in  so  far  as  sight  is  concerned,  and  unless  very 
pronounced  and  associated  with  wide-spread  ophthalmo- 
scopic changes,  should  not  in  themselves  call  for  the 
induction  of  premature  labor,  for  literature  shows  that, 
in  such  cases,  the  sight  is  completely  restored  after 
labor.  This  is  especially  true  when  the  retinitis  shows 
itself  in  the  last  two  weeks  of  pregnancy."  ("  Johns  Hop- 
kins Hospital  Bulletin,"  Baltimore,  June  and  July,  1894). 

The  following  abstract  of  a  discussion  of  the  sub- 
ject before  the  Medical  Society  of  Berlin,  January  23, 
1895,  by  Dr.  Silex  is  worthy  of  record.  The  report  is 
taken  from  the  ^^ Annals'  d' Occulistique.'''' 


94c  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

"  All  the  peculiarities  of  albuminuric  retinitis  in 
pregnancy  are  not  yet  well  known.  Dr.  Silex  is  in  pos- 
session of  preparations  which  show  the  vessels  intact. 

"  Its  symptomatology  and  prognosis  are  very  in- 
exactly treated  in  literature,  and  its  therapeutics  have 
been  much  neglected.  The  author  has  given  much  at- 
tention to  this  special  pathological  subject  for  many 
years,  and  has  arrived  at  definite  conclusions  in  regard 
to  the  affection. 

"  To  form  a  judgment  of  a  case,  it  is  necessary 
first  to  make  a  critical  ophthalmoscopic  examination  of 
the  retinal  arteries.  In  the  first  stages  of  the  disease, 
the  central  artery  is  often  seen  with  the  erect  image 
transformed  into  a  large  white  cord.  This  is  produced 
by  dilatation  of  the  peri-vascular  lymphatic  space.  This 
change  may  disappear,  but  hyaline  degeneration  of  the 
arteries  threatens  the  canals  of  the  vessels,  which  may 
compromise  the  function  of  the  internal  layers  of  the 
retina  and  produce  atrophy  of  this  membrane  and  of  the 
optic  nerve.  If  the  vessels  are  normal,  albuminuric 
retinitis  presents  little  danger.  This  form  of  retinitis 
may  arise  from  an  affection  of  the  kidneys  during  preg- 
nancy, an  acute  or  chronic  nephritis,  the  general  symp- 
toms of  which  are  early  developed.  The  visual  distur- 
bances develop  slowly,  most  frequently  in  the  second 
period  of  pregnancy,  especially  in  primiparae.  If  they 
develop    rapidly,    chronic    nephritis    must    be    assumed. 


RETINITIS  ALBUMINUKICA  OF  PREGNANCY.  95 

After  delivery,  vision  is  established  more  or  less  com- 
pletely. 

"In  22  patients  examined  during  a  considerable 
period,  ii  recoverd  vision  more  than  ^,  lo  others  re- 
mained with  a  lesser  degree  of  acuity,  and  five  of  them 
were  almost  blind.  This  unfortunate  result  was  due  to 
atrophy  of  the  optic  nerve,  to  retino-choroiditis,  and  to 
detachment  of  the  retina,  which  occurred  at  a  later 
stage  in  both  eyes.  These  figures  are  so  important, 
from  a  social  point  of  view,  that  Silex  advises  interfer- 
ence with  pregnancy  in  all  cases  where  retinitis  is 
found.  Its  prognosis  is  indeed  uncertain ;  the  women 
are  frequently  attacked  with  eclampsia,  and  the  hope  of 
a  living  child  is  but  faint.  In  chronic  nephritis,  dan- 
ger to  the  life  of  the  mother  and  child  settles  the  ques- 
tion of  interference  ;  in  case  of  nephritis  of  pregnancy, 
premature  delivery  is  not  advocated,  as  in  several  cases 
good  vision  has  returned  after  expectant  treatment. 

"The  condition  of  the  retinal  vessels  should  de- 
cide the  question  of  interference.  For  example,  in  two 
pregnant  women,  at  the  commencement  of  the  eighth 
month,  one  having  an  acuity  of  -^,  and  the  other  of 
^ig,  one  might  be  authorized  to  perform  premature  de- 
livery in  the  first  case  on  account  of  the  vascular 
changes,  while  one  should  wait  in  the  second.  It  is  in- 
teresting that  Dr.  Silex  has  been  able  to  find  large 
quantities  of  albumin  in  the  urine  during  one  or  two 
years  without  development   of  chronic   nephritis   in  sev- 


96  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

eral  women  in  whom  the  retinal  lesion  had  disappeared 
and  the  general  health  had  remained  good.  The  long 
duration  of  albuminuria  has  not  always  a  bad  progno- 
sis when  it  can  be  attributed  to  a  renal  affection  of 
pregnancy." 

It  should  be  remembered,  as  Noyes  remarks,  that 
"  the  amaurosis  of  pregnancy  may  be  independent  of 
uraemia  and  without  changes  in  the  eye  grounds,  but 
with  a  tendency  to  atrophy  of  the  optic  nerve." 

RETINITIS   SYPHILITICA. 

Syphilis  is  the  cause  of  many  cases  of  retinitis. 
It  occurs  in  the  hereditary  as  well  as  the  acquired  form. 
It  is  usually  among  the  secondary  symptoms,  more 
rarely  a  tertiary  development.  It  may  occur  as  a  prim- 
ary affection,  or  it  may  accompany  iritis  or  choroiditis 
or  cerebral  syphilis. 

It  presents  no  distinguishing  or  pathognomonic 
features.  It  usually  exhibits  the  ophthalmoscopic  pic- 
ture of  a  simple  retinitis  without  marked  exudation  or 
hemorrhage.  There  may  be  an  unusual  tendency  to  the 
development  of  connective  tissue  in  the  retina  and  in 
the  vitreous,  constituting  the  so-called  retinitis  prolifer- 
ans.  A  marked  tendency  to  relapse  is  a  somewhat 
characteristic  feature  of  syphilitic  retinitis.  A  more  fre- 
quent localization  in  the  central  portions  of  the  retina, 
and  a  more  frequent  sequence  of  optic  nerve  atrophy  are 
also  indicative  of  a  syphilitic  origin. 


RETINITIS  DIABETICA.  97 

RETINITIS   DIABETICA. 

Diabetic  retinitis  is  of  rare  occurrence  and  indi- 
cates a  severe  type  of  the  disease.  It  presents  many 
points  of  similarity  to  nephritic  retinitis,  but  there  are 
also  some  peculiarities  which  the  specialist  will  recog- 
nize. In  brief,  the  following  points  may  be  mentioned : 
irregular  distribution  of  the  exudation,  less  frequent  im- 
plication of  the  macula,  and  when  in  this  location,  lack- 
ing the  stellate  arrangement,  absence  of  neuritis,  and 
the  punctate  form  of  the  hemorrhages,  which  are  also 
of  more  frequent  occurrence.  The  vascular  changes  are 
more  marked  in  the  smaller  vessels,  while  the  larger 
ones  suflfer  equally  or  to  a  greater  extent  in  albuminuric 
retinitis.  The  latter  is  almost  always  binocular,  while 
the  diabetic  form  is   frequently  confined  to  one  eye. 

"  Every  diabetic  disease  of  the  retina  is  of  serious 
diagnostic  import,  showing  degeneration  of  the  vessels, 
and  showing  liability  to  cerebral  hemorrhage  which  is 
more  frequent  than  in  the  eye." 

RETINITIS   LEUKAEMICA. 

Retinitis  with  leucocythemia  is  not  common,  and 
is  of  no  special  diagnostic  importance.  The  fundus 
sometimes  presents  a  peculiar  orange  hue.  As  has  been 
previously  remarked,  it  may  closely  simulate  the  picture 
of  retinitis  albuminurica,  and  the  same  is  true  of  the 
7 


98  THE   EYE   AS   AN   AID   IN  GENERAL   DIAGNOSIS. 

retinitis  which  sometimes  develops  in  the  course  of  per- 
nicious anaemia. 

GOUTY    RETINITIS. 

Dr.  Bull,  of  New  York,  in  the  "  N.  Y.  Medical 
Journal "  for  August,  1893,  describes  the  features  of  this 
form  of  retinitis.     He  says : 

"An  arterio-  and  phlebo-sclerosis  of  the  retina  is 
noticed  by  ophthalmoscopic  examination,  and  the  micro- 
scope shows  degeneration  in  the  vessels  of  the  choroid 
and  optic  nerve  as  well.  A  pathognomonic  symptom  is 
a  peculiar  yellowish  granular  exudation  in  the  retina 
around  the  posterior  pole  of  the  eye,  usually  leaving 
the  macula  intact,  and  situated  mainly  in  the  nerve  fibre 
layer,  although  found  to  some  extent  in  all  the  layers 
except  the  rods  and  cones.  The  changes  in  the  fundus 
are  always  bilateral,  though  rarely  symmetrical  in  both 
eyes.  There  is  marked  impairment  of  central  vision, 
but  there  is  little  or  no  loss  of  peripheral  vision.  The 
loss  of  central  visual  perception  is  progressive  up  to  a 
certain  point,  but  blindness  never  results.  Hemorrhages 
are  rare,  except  in  the  early  stages.  In  the  later  stages 
the  walls  are  strengthened  by  the  deposits." 

AFFECTIONS  OF  THE  OPTIC  NERVE. 

In  describing  the  relation  of  neuritis  and  atrophy 
of  the  optic  nerve  to  intra-cranial  and  spinal  affections, 
it  is  proper  to  remark  by  way  of  introduction,  that  coin- 


CHOKED  DISC.  99 

cident  cerebral  or  spinal  diseases  and  ocular  affections 
do  not  always  or  necessarily  stand  in  the  relation  of 
cause  and  effect.  A  certain  condition  of  the  optic  nerve 
revealed  by  the  ophthalmoscope  may  be  idiopathic,  or, 
as  we  have  seen,  it  may  occur  as  a  secondary  result  of 
various  general  and  local  diseases.  Again,  habitual  or 
severe  headache  associated  with  progressive  failure  of 
sight,  is  not  always  a  sign  of  brain  trouble,  but  may  be 
due  simply  to  the  effort  to  see  distinctly,  where  the  vis- 
ion is  defective  from  strictly  ocular  disorders. 

Neuritis  is  very  frequently  caused  by  brain 
disease,  especially  by  tumor,  meningitis  and  abscess. 
Different  authors  estimate  the  proportion  of  cases  of 
brain  tumor  in  which  neuritis  exists  as  from  70  to  90 
per  cent.  Hence,  in  doubtful  cases,  a  knowledge  of  its 
presence  or  absence  is  of  great  value.  It  usually  takes 
the  form  of 

CHOKED    DISC. 

The  development  of  a  neoplasm  in  an  unyielding 
skull  necessarily  causes  an  increase  of  the  intra-cranial 
pressure.  One  result  of  this  increased  pressure  is  a 
serous  and  lympathic  stasis  in  the  optic  nerve  with 
congestion,  oedema  and  swelling  of  the  optic  papil- 
la visible  with  the  ophthalmoscope,  and  constituting 
choked  disc.  Another  result  of  increased  intra-cranial 
pressure  is  a  displacement  of  the  fluid  contained  in  the 
sub-arachnoid  and   sub-dural  spaces.       Some  of  the  fluid 


100         THE   EYE   AS   AN  AID   IN  GENERAL   DIAGNOSIS. 

would  escape  through  the  foramen  magnum  into  the 
lymph  spaces  of  the  cord,  while  a  portion  would  distend 
the  sheaths  of  the  optic  nerve,  which,  as  we  have  seen, 
are  tubular  prolongations  of  these  cavities.  Thus  the 
congestion  and  oedema  of  the  papilla  would  be  in- 
creased, and  inflammation  and  exudation  and,  perhaps, 
hemorrhage  would  develop,  and  the  choked  disc  become 
a  choked  neuritis.  Both  of  these  conditions  indicate, 
with  very  few  exceptions,  an  increase  of  the  intra-cra- 
nial  pressure. 

The  intensity  of  the  symptoms  bears  a  pretty 
constant,  though  not  invariable,  ratio  to  the  amount  of 
the  increased  pressure,  and  as  brain  tumors  cause  a 
greater  increase  of  pressure  than  any  other  morbid  pro- 
cess, choked  disc  has  come  to  be  considered  as  almost 
pathognomonic  of  the  existence  of  a  tumor.  It  is  evi- 
dent that  mechanical  distention  of  the  nerve  sheaths  is 
not  the  only  factor  in  causing  the  neuritis,  from  the  fact 
that  all  cases  of  brain  tumor  are  not  associated  with  it, 
and  also  that  very  small  tumors  produce  it,  while  occa- 
sionally very  large  tumors  exist  without  it  With 
chronic  hydrocephalus  also,  in  which  the  intra-cranial 
pressure  is  markedly  increased,  we  find  as  a  rule  sim- 
ple atrophy  of  the  optic  nerve  and  no  inflammatory 
changes.  "  The  propagation  of  tissue  irritation  "  is  a 
recent  rather  ambiguous  expression  to  explain  the  modus 
operandi  of  such  an  associated  condition.  It  is  less  fre- 
quent   with    neoplasms    of   the   frontal    lobes   than  with 


CHOKED  DISC.  101 

those  situated  more  posteriorly,  especially  in  the  cerebel- 
lum. When  in  one  frontal  lobe,  a  unilateral  choked 
disc  might  be  caused,  but  whenever  any  variety  of  neu- 
ritis is  due  to  an  intra-cranial  affection  of  whatever 
kind,  it  is,  with  few  exceptions,  bilateral.  Hence,  we 
may  lay  down  the  rule  that  a  unilateral  neuritis  is 
probably  7wt  dependent  upon  cerebral  disease. 

Choked  disc  is  not  an  early  symptom  of  a  cere- 
bral tumor,  indeed,  a  tumor  may  exist  for  a  long  time 
without  causing  choked  disc.  This  happens  when  the 
tumor  is  of  slow  growth.  On  the  other  hand,  it  may 
occur  suddenly  in  connection  with  a  chronic  neoplasm. 
A  rapidly  growing  tumor  never  causes  a  slowly  develop- 
ing neuritis,  although  the  reverse  may  be  true ;  that '  is, 
a  slowly  developing  tumor  may  take  on  a  sudden  growth 
with  rapid  development  of   neuritis  as  mentioned  above. 

A  cerebral  abscess  frequently  induces  optic  neu- 
ritis, but  there  are  no  reliable  ophthalmoscopic  data  for 
arriving  at  a  differential  diagnosis  between  the  latter 
affection  and  a  brain  tumor,  although  we  usually  find 
"  less  swelling  and  more  pronounced  inflammation "  in 
cerebral  abscess. 

Other  diseases  which  cause  marked  increase  of 
intra-cranial  pressure  rarely  cause  true  choked  disc. 
Such  diseases  are  tubercular  meningitis,  chronic  hydro- 
cephalus, extensive  cerebral  hemorrhages  and  pachy- 
meningitis hemorrhagica.  It  has  also  occasionally  been 
found  with  tumors  of  the  spinal  cord,  with  albuminuria, 
diabetes,  leukaemia  and  after  profuse  hemorrhages, 


102  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

In  conclusion  it  may  be  remarked  that  the  diag- 
nostic significance  of  choked  disc  is  extremely  valuable, 
indicating  marked  increase  of  intra-cranial  pressure,  and 
affording  strong  presumptive  evidence  of  a  tumor  as  the 
cause  of  the  increased   pressure. 

SIMPLE    NEURITIS. 

The  distinction  between  choked  disc  and  simple 
neuritis  is  rather  one  of  degree  than  of  kind,  and  a 
brain  tumor  may  be  accompanied  with  a  simple  neuri- 
tis without  strong  swelling  or  prominence  of  the  papilla. 
This  is  more  apt  to  be  the  case  when  the  tumor  is  in 
the  frontal  lobe  not  far  distant  from  the  optic  nerve. 
Thus  a  unilateral  neuritis  acquires  additional  diagnostic 
importance.  A  true  choked  disc  could  hardly  develop 
idiopathically,  but  simple  neuritis  sometimes  does,  after 
exposure  to  cold  for  example,  so  that  we  cannot  say  pos- 
itively that  such  a  condition  necessarily  implies  the  ex- 
istence of  cerebral  disease,  but  it  affords  strong  presump- 
tive evidence  of  an  "irritative  process  within  the 
skull."  A  considerable  degree  of  inflammation  may  ex- 
ist without  impairment  of  sight,  and  may  be  an  early 
symptom  before  headache,  etc.,  appears.  Hence  the  im- 
portance of  ophthalmoscopic  examination  in  all  doubtful 
cases  is  apparent,  and  in  obscure  cases  without  marked 
mental  symptoms,  pain  or  other  pronounced  indication 
of  cerebral  disease,  the  ophthalmoscope  may  establish 
the  diagnosis. 


SIMPLE  NEURITIS,  103 

With  the  exception  of  intra-cranial  neoplasms, 
chronic  meningitis  is  the  most  frequent  cause  of  neuri- 
tis, and  it  is  easy  to  understand  how  the  inflammation 
extends  in  such  cases  by  continuity  of  structure,  so  that 
here  we  more  frequently  find  an  interstitial  or  a  peri- 
neuritis. It  is  found  in  the  majority  of  cases,  and 
hence  is  an  important  aid  in  differential  diagnosis.  It 
does  not  often  occur  early  in  the  disease.  Acute  men- 
ingitis, either  tuberculous  or  non-tuberculous,  is  seldom 
accompanied  with  marked  ophthalmoscopic  changes,  nor 
do  we  often  find  them  with  cerebro-spinal  meningitis. 
Knies,  on  the  contrary,  asserts  that  neuritis  is  quite  fre- 
quent in  the  latter  disease. 

It  has  been  observed  that  choked  disc  may  re- 
sult in  consequence  of  cerebral  gummata,  but  syphilis 
may  attack  the  nerve  of  one  or  both  eyes  directly,  giv- 
ing rise  to  simple  neuritis,  either  as  an  isolated  mani- 
festation, or  in  connection  with  affections  of  the  cerebral 
nerves. 

Affections  of  the  optic  nerve  are  of  value  in  in- 
juries to  the  skull,  enabling  one  occasionally  to  locate  a 
fracture  at  the  orbital  foramen  or  in  the  immediate 
vicinity  of  the  optic  chiasm. 

Similarly,  neuritis  developing  after  an  injury  to 
the  spine,  concussion,  "  railway  spine,"  etc.,  points  to 
the  cilio-spinal  region  as  the  seat  of  the  lesion. 

Neuritis  is  sometimes  of  malarial  origin,  in  which 
case  it  is  usually  bilateral,  and   it   occasionally  develops 


104  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

in  the  course  of    typhoid   and    other   infectious  diseases. 

Dr.  White,  of  Richmond,  Va.,  reports  in  the 
"Medical  News"  for  July  15,  1893,  a  case  of  optic  neu- 
ritis occurring  in  the  third  week  of  typhoid,  and  a  second 
case  where  optic  atrophy  was  noted  four  months  after 
an  attack  of  typhoid  fever,  during  the  course  of  which 
vision  had  begun  to  fail,  and  had  continued,  notwith- 
standing the  improvement  in  the  general  health.  He 
also  cited  a  case  of  blindness  after  malarial  intermittent. 

Gowers  says  "optic  neuritis  may  follow  scar- 
let fever  without  any  organic  change  in  the  brain  to 
cause  it,  hence  the  inference  that  scarlet  fever  poison 
has  a  special  action  on  the  nervous  system.*' 

Neuritis  and  retinitis  are,  at  times,  complications 
of  dementia  paralytica  and  multiple  sclerosis.  Multiple 
neuritis,  or  pseudo  tabes,  sometimes  occasions  an  axial 
neuritis  with  central  scotoma,  simulating  toxic  ambly- 
opia. This  is  a  valuable  diagnostic  sign  between  true 
and  false  tabes,  in  the  former  of  which  we  meet  with 
simple  atrophy  of  the  nerve  without  inflammation. 
Similar  symptoms  occasionally  result  from  the  influence 
of  gout. 

In  such  cases  there  may  be  also  chalky  deposits 
along  the  vessels  of  the  conjunctiva. 

ATROPHY  OF  THE   OPTIC   NERVE. 

The  secondary  result  of  neuritis,  and  especially 
of   choked  neuritis,  is  atrophy,  from   compression  of  the 


ATROPHY  OF  THE  OPTIC  NERVE.  105 

nervous  elements  by  the  vascular  engorgement  and  in- 
flammatory exudation.  This  is  called  consecutive  or 
secondary  atrophy,  in  distinction  from  simple  atrophy 
which  is  not  a  result  of  inflammation.  The  two  forms 
can  be  differentiated  by  ophthalmoscopic  examination, 
but  a  discussion  of  the  points  of  difference  is  not  within 
the  scope  of  this  treatise.  If,  in  the  course  of  a  brain 
tumor,  we  have  the  picture  of  inflammatory  atrophy  of 
the  optic  nerve,  it  demonstrates  the  previous  existence 
of  choked  disc,  and  also  that  the  tumor  is  a  chronic 
condition,  because  atrophy  requires  considerable  length 
of  time  for  its  development.  Thus  we  see  that  the  con- 
dition of  the  optic  nerve  is  of  prognostic  as  well  as 
diagnostic  importance.  In  exceptional  cases  a  brain  tu- 
mor causes  simple  atrophy  by  direct  pressure  upon  the 
optic  tract,  chiasm  or  nerve.  When  only  one  tract  suf- 
fers compression,  corresponding  portions  of  each  nerve 
will  show  atrophic  changes  while  the  remaining  halves 
will  be  uninjured.  When  one  nerve,  between  the  chiasm 
and  the  globe  suffers,  monocular  atrophy  ensues.  Sim- 
ple atrophy  may  result  from  cerebral  meningitis,  and  it 
is  often  an  accompaniment  of  multiple  sclerosis,  but  in 
the  latter  disease  it  is  usually  incomplete  in  its  develop- 
ment. It  occurs  late  in  the  course  of  progressive 
paralysis,  but  sometimes  it  is  an  early  manifestation. 

It  may  also  be  associated  with  dementia  and 
idiocy.  The  most  frequent  cause  of  simple  optic  nerve 
atrophy  is  tabes   dorsalis,  in  which   disease   the   atrophy 


106         THE   EYE  AS  AN  AID   IN  GENERAL   DIAGNOSIS. 

begins  in  the  outer  temporal  side.  In  its  fully  de- 
veloped stage  it  resembles  a  glaucomatous  excavation. 
It  is  often  an  early  symptom,  and  is  ordinarily  asso- 
ciated with  "Argyll-Robertson  pupil "  and  spinal  myosis, 
to  each  of  which  reference  has  been  previously  made. 
It  may  be  many  years  before  the  essential  features  of 
tabes  develop.  It  may  occur  in  any  stage  of  the  dis- 
ease, and  the  rapid  or  slow  development  of  the  optic 
nerve  affection  is  in  inverse  ratio  to  the  motor  symp- 
toms, so  that  it  becomes  of  prognostic  as  well  as  diag- 
nostic significance.  When  the  loss  of  sight  is  rapid,  the 
locomotor  ataxia  is  usually  of  slow  development  and 
vice  versa.  Sometimes  when  the  atrophy  does  not  appear 
until  the  tabetic  symptoms  are  well  developed,  a  tem- 
porary arrest  of  the  latter  follows  the  appearance  of  the 
visual  symptoms.  Berger  considers  the  association  of 
diminished  sensibility  of  the  conjunctiva  and  cornea,  and 
false  localization  of  sensation  with  optic  atrophy  "a 
strong  presumptive  evidence  in  favor  of  a  tabetic  origin 
of  this  atrophy." 

Both  eyes  are  affected,  but  not  always  simultane- 
ously. There  may  be  a  considerable  interval,  perhaps 
several  years,  before  the  second  eye  is  affected.  Knies 
says  the  "proportion  of  atrophy  with  tabes  is  variously 
estimated  at  from  10-35  P^^  cent."  Galezowski  says, 
"two-thirds  of  all  optic  nerve  atrophies  are  tabetic. 
Every  genuine  gray  atrophy  raises  suspicion  of  tabes." 
The  length  of  time  that  elapses  between  the  commence- 


ATROPHY  OF  THE  OPTIC  NERVE.  107 

ment  of  the  process  and  complete  blindness  varies  from 
two  months  to  seventeen  years.  The  average  time  is 
three  years. 

Knies  says  that  in  pseudo  tabes  we  find  a  "  gray- 
ish-red opacity  and  obliterated  borders  of  the  nasal  half 
of  the  papilla,  with  atropic  discoloration  of  the  outer 
halves." 

A  similar  condition  is  seen  in  toxic  amblyopia. 

Acute  and  chronic  myelitis  cause  neuritis  or  sim- 
ple atrophy.  The  appearance  of  the  optic  nerve  and 
retina  affords  no  reliable  indication  of  the  amount  of 
vision.  Marked  deviation  from  a  normal  standard  may 
exist  for  a  long  time  before  the  sight  is  noticeably 
affected;  hence  the  importance  of  an  early  ophthalmo- 
scopic examination. 


CHAPTER  V. 

THE    SIGHT  AND    THE    FIELD   OF   VISION.      THE    SIGNIFI- 
CANCE OF  VISUAL    DISORDERS    DUE  TO    LESIONS    IM- 
PLICATING    THE     INTRA-CRANIAL     COURSE     OF 
THE  OPTIC  NERVE   FIBRES,  INCLUDING  AF- 
FECTIONS    OF     THE      CHIASM,      THE 
TRACT,   THE  OPTIC  GANGLIA, 
AND     THE      CORTICAL 
VISUAL  CENTRES, 
AND 
'psychic   visual  DISORDERS. 

In  the  preceding  chapters  we  have  discussed  the 
significance  of  pathological  conditions  of  the  various  tis- 
sues of  the  eye  and  its  adnexa.  We  have  now  to  con- 
sider certain  subjective  disorders  of  vision,  irrespective 
of  any  ophthalmoscopic  changes  which  may  or  may  not 
accompany#them.  Such  conditions  are  of  extreme  value 
in  the  localization  of  intra-cranial  affections,  and  occa- 
sionally in  the  elucidation  of  obscure  constitutional  dis- 
eases. 

Three  methods  of  estimating  the  visual  acuity  are 
commonly  employed.  First  by  the  use  of  test  type  of 
different  sizes,  each  of  which  is  seen  by  a  normal  eye 
at  a  given  distance.     The  amount  of  vision  is  then  ex- 

(108) 


THE  SIGHT  AND  THE  FIELD  OF  VISION.  109 

pressed  by  a  fraction,  the  numerator  of  which  indicates 
the  distance  at  which  the  patient  reads  the  type,  and 
the  denominator  the  distance  at  which  the  same  type 
should  be  read.  V=It5  ^^^  instance,  indicates  that  at 
a  distance  of  twenty  feet,  the  patient  cannot  read  print 
smaller  than  that  which  is  normally  read  at  fifty  feet. 
His  vision  is  then  f  of  the  normal  standard. 

When  the  sight  is  too  defective  to  be  tested  in 
that  way,  we  ascertain  at  what  distance  he  can  count 
the  fingers  of  the  examiner,  and  lastly  whether  he  can 
still  distinguish  light  from  darkness. 

Blindness,  partial  or  complete,  sudden  or  gradual, 
temporary  or  permanent,  occurs  very  frequently  in  the 
course  of  intra-cranial  and  spinal  diseases,  and  while  the 
mere  subjective  sensation  of  failing  sight,  without  oph- 
thalmoscopic findings,  affords  by  itself  no  basis  for  the 
diagnosis  of  the  nature  of  the  causative  lesion,  it  does 
afford  very  valuable  data  for  determining  the  situation 
of  such  a  lesion.  When  it  affects  both  eyes,  the  pre- 
sumption is  warrantable  that  the  cause  lies  at  or  be- 
hind the  chiasm,  if  we  except  a  simultaneous  lesion  of 
both  optic  nerves,  which,  though  possible,  is  extremely 
rare.     (Double  retro-bulbar   neuritis). 

One  sided  blindness,  when  not  dependent  upon 
an  ocular  affection,  must  be  referred  to  the  optic  nerve 
between  the  globe  and  the  chiasm,  constituting  a  retro- 
bulbar neuritis.  A  discussion  of  this  condition  is  not 
relevant  in  this   connection.     (See   the   chapter  on  toxic 


110  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

amblyopia).  A  central  scotoma,  that  is,  a  dark  spot  in 
the  centre  of  the  visual  field,  which  is  one  of  the  char- 
acteristic features  of  retro-bulbar  neuritis,  does  not,  there- 
fore, necessarily  indicate  a  central  lesion.  It  is  other- 
wise with  bilateral  and  symmetrical  defects  affecting 
corresponding  portions  of  both  visual  fields.  Such  dis- 
orders indicate  a  lesion  involving  the  intra-cranial 
course  of  the  optic  nerve  fibres,  and  a  clear  understand- 
ing of  the  anatomical  path  of  these  fibres  is  essential 
for  an  appreciation  of  the  diagnostic  significance  of  the 
various  forms  of  hemianopia.  It  will  be  profitable, 
therefore,  at  this  point,  to  review  the  course  and  ulti- 
mate termination  of  the  optic  nerve  fibres,  and  to  en- 
quire into  the  function  of  the  primary  optic  ganglia  and 
the  cortical  visual  centres. 

The  optic  tracts  from  either  side  unite  at  the 
chiasm  where  they  undergo  a  semi-decussation.  The 
fibres  of  the  right  tract  are  distributed  to  the  right  half 
of  each  retina,  and  those  of  the  left  tract  to  the  left 
half  of  each  retina.  Each  optic  nerve  thus  contains 
both  crossed  and  uncrossed  fibres.  The  right  nerve,  for 
instance,  contains  uncrossed  fibres  from  the  right  tract, 
which  are  distributed  to  the  right,  or  temporal  side,  of 
the  retina,  and  also  crossed  fibres  from  the  left  optic 
tract,  which  are  distributed  to  the  nasal  half  of  the  right 
retina.  Each  optic  tract  contains  the  fibres  coming  from 
the  corresponding  halves  of  the  retinae  of  the  two  eyes, 
the  right  tract  those  from  the  right  halves,  and  the  left 


PLATE  I. 


THE  SIGHT  AND  THE  FIELD  OF  VISION.  Ill 

tract  those  from  the  left  halves.  The  uncrossed  bundle 
of  fibres  lies  at  the  outer  edge  of  the  chiasm  on  either 
side. 

Plate  I  illustrates  the  course  of  the  fibres  from 
either  tract  to  the  eye. 

Passing  backward  along  the  base  of  the  brain, 
some  of  the  fibres  enter  the  optic  thalamus,  particularly 
the  posterior  portion  known  as  the  pulvinar,  but  the 
larger  part  enter  the  external  geniculate  body.  In  both 
of  these  bodies  the  optic  nerve  fibres  are  augmented  by 
axis  cylinders  from  their  ganglion  cells,  and  then  pass 
upwards  to  the  cortex  of  the  occipital  lobe  by  way  of 
the  internal  capsule,  constituting  the  optic  radiation  of 
Gratiolet. 

Thus  both  the  optic  thalamus  and  the  external 
corpus  geniculatum  are  directly  concerned  with  con- 
scious vision,  and  a  lesion  of  either  interrupts  the  direct 
line  of  conduction  from  the  eye  to  the  visual  centres. 
Fibres  also  pass  from  the  thalamus  to  the  third  nu- 
cleus, and  are  concerned  with  the  reflex  movements  of 
the  iris.  A  few  fibres  of  the  optic  tract  pass  to  the  an- 
terior corpora  quadrigemina,  which  bodies  have  no 
relation  to  conscious  vision,  but  preside  over  invol- 
untary conjugate  and  associated  ocular  movements  de- 
pendent upon  visual  impressions,  "  and  transmit  to  the 
visual  sphere  a  knowledge  of  involuntary  movements 
which  follow  light  stimuli." 


112  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Still  other  fibres  pass  downward  to  the  posterior 
columns  of  the  cord  and  subserve  the  involuntary  re- 
flexes of  the  general  muscular  system  due  to  visual  im- 
pressions from  the  opposite  half  of  the  visual  field.  By 
means  of  these  fibres  is  explained  the  visual  symptoms 
which  occur  in  the  course  of  locomotor  ataxia.  A  few 
'fibres  also  pass  from  the  tract  to  the  internal  geniculate 
body  and  from  thence  to  the  posterior  corpora  quadri- 
gemina,  but  they  are  unimportant  for  our  consideration, 
as  these  two  bodies  have  no  relation  with  the  function 
of  sight.  It  has  been  asserted  that  fibres  pass  directly 
from  the  tract  to  the  visual  centres  without  entering 
the  thalamus  or  geniculate  body,  but  this  has  not  been, 
positively  demonstrated. 

Knies  considers  it  probable  that  a  "  union  of  the 
binocular  visual  impressions  of  corresponding  halves  of 
the  fields  of  vision  into  a  harmonious  single  impression 
takes  place  in  the  primary  optic  ganglia."  The  harmo- 
nious single  impression  thus  formed  is  thence  transmit- 
ted to  the  cortical  centre,  and  thus  is  exemplified  the 
function  of  all  the  basal  ganglia,  which  is  to  receive, 
regulate  and  control  impressions  from  all  outside  sta- 
tions, and  to  transmit  them  to  their  respective  cerebral 
centres. 

But  the  optic  ganglia  have  other  important  func- 
tions in  presiding  over  the  involuntary  movements  of 
the  head,  neck  and  extremities,  dependent  upon  visual 
impressions   received  from    the  opposite  half  of  the  vis- 


THE  SIGHT  AND  THE  FIELD  OF  VISION.  113 

ual  field,  as  well  as  those  ocular  reflex  movements  asso- 
ciated with  sensory  impressions  derived  from  the  ear, 
the  face  and  distant  portions  of  the  body. 

It  is  at  the  visual  centre  in  the  cortex  of  the 
occipital  lobe  that  visual  impressions  first  awaken  con- 
scious perceptions.  From  this  position  originate  im- 
pulses for  conscious  ocular  movements  toward  the  oppo- 
site side,  and  here  memory  pictures  are  stored,  by  virtue 
of  which  an  object  once  seen  is  recognized.  The  whole 
area  of  the  occipital  cortex  is  regarded  as  directly  re- 
lated to  the  faculty  of  vision,  but  the  cuneus  is  the 
most  important  portion,  and  lesions  here  produce  the 
most  pronounced  and  serious  impairment  of  sight. 

The  researches  of  Henschen  (see  "  Klinische  und 
Anatomische  Beitrdge  zur  Pathologie  des  Gehirns,"  Upsala, 
1892),  seem  to  indicate  that  the  immediate  vicinity  of 
the  calcarine  fissure  is  the  locality  where  a  lesion  caus- 
ing permanent  hemianopia  is  found. 

By  means  of  commissural  fibres  between  the  vis- 
iial  centres  and  the  higher  intellectual  centres  visual 
impressions  excite  mental  processes. 

We  are  now  in  a  position  to  discuss  intelligently 
the  data  for  the  localization  of  intra-cranial  affections 
which  are  furnished  by  lesions  involving  the  path  of 
the  optic  nerve  fibres  posterior  to  the  orbit. 

Such  binocular  subjective  symptoms  may  be  con- 
veniently classified  under  two  heads,  viz. : 


114  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

1.  Changes  in  the  form  and  extent  of  the  visual 
fields    constituting   the    various    forms    of    hemianopsia. 

2.  Amaurosis  and  amblyopia  (or,  more  correctly, 
cortical  blindness),  and  the  varied  forms  of  psychic  vis- 
ual disorders. 

A  knowledge  of  the  normal  boundaries  of  the 
visual  fields  for  form  and  color  is  essential  for  a  recog- 
nition of  pathological  defects  in  its  dimensions  or  out- 
line. When  the  eyes  are  fixed  upon  a  given  object 
its  retinal  image  is  formed  upon  the  macula  lutea 
of  each  eye,  the  most  sensitive  portion  of  the  retina, 
and  at  the  same  time  rays  of  light  emanating  from 
objects  on  all  sides  of  the  object  of  fixation  enter  the 
pupil,  and  form  more  or  less  distinct  images  upon 
peripheral  parts  of  the  retina.  It  is  evident  that  the 
farther  such  visual  images  are  projected  into  space, 
the  larger  the  resulting  visual  field  will  be,  but  it  will 
always  represent  a  certain  number  of  degrees  of  the  cir- 
cumference of  a  circle,  however  large  or  small  such  a 
circle  may  be.  It  is  evident  also  that  the  vision  will 
be  more  extensive  on  the  temporal  side  than  in  other 
directions,  because  the  outlines  of  the  orbit  and  the 
bridge  of  the  nose  will  obstruct  the  course  of  peripheral 
rays  in  other  directions,  and  that  the  limits  in  individ- 
ual cases  will  vary  slightly  according  to  the  conforma- 
tion of  the  face.  The  physiological  limits  of  the  visual 
field  for  form  are,  approximately,  90°  outward,  60° 
above,  50°  on  the  nasal  side,  and  65°  below.    The  field 


PLATE  II. 


LEFT  VISUAL  FIELD.    RIGHT  VIS  UAL  FIELD. 

F,\-nfJnnPnin/  FtxatiOR  PoVlt . 


L.  Genicu/ate  3ody 
L  Int.  Capsule 


'^^^/^fff//  Corff^ 


n.  Orr/jji^^^' 


THE  SIGHT  AND  THE  FIELD  OF  VISION. 


115 


for  color  is  not  coextensive  with  that  for  form,  and  dif- 
fers with  the  different  colors,  that  for  blue  being  the 
largest,  and  that  for  green  the  smallest.  The  accompa- 
nying chart  illustrates  the  physiological  limits  of  the 
visual  fields. 


The  examination  of  the  visual  field  is  best  made 
by  means  of  the  perimeter.  There  are  various  patterns 
of  this  instrument  in  the  market.  The  latest  and  best 
design  is  made  by  E.  B.  Meyrowitz,  of  new  York,  a  cut 
of  which  is  appended.  The  special  feature  of  this  in- 
strument is  that  it  is  self-recording,  a  desideratum  which 


116         THE  EYE   AS   AN   AID   IN   GENERAL  DIAGNOSIS. 


has  long  been  sought   but  never  practically  attained  be- 
fore. 

A  perimeter  will  hardly  be  found  in  the  office  of 
the  general  practitioner,  and,  in  its  absence,  an  approxi- 


mate estimate  of  any  pathological  change  in  the  visual 
field  can  be  gained  in  the  following  way  : 

The  patient,  seated  directly  in  front  of  the  physi- 
cian and  about  two  feet  distant,  fixes  with  his  left  eye, 
for  instance,  the  right  eye  of  the  examiner,  or  vice  versa, 
the  other  eye  of  both  physician  and  patient  being 
closed.     Then    the    farthest    point    in    all    directions,  at 


HEMIANOPSIA.  117 

which  the  movement  of  the  physician's  hand  (held  mid- 
way between  their  two  faces,)  can  be  seen  by  the  pa- 
tient while  the  position  of  his  eye  is  unchanged,  gives 
the  outline  of  his  visual  field.  By  comparing  this  with 
the  physician's  field,  simultaneously  delineated,  any  de- 
cided abnormality  is  detected. 

HEMIANOPSIA. 

By  this  term  is  understood  a  complete  or  partial 
loss  of  sight,  affecting  one-half  of  each  visual  field. 
Care  is  to  be  exercised  not  to  confound  it  with  blind- 
ness of  one  eye. 

Hemianopsia  may  be  classified  as  heteronymous 
or  homonymous.  In  the  former,  unsymmetrical  parts  of 
the  visual  field  are  involved,  and  it  may  again  be  desig- 
nated as  heteronymous  medial  hemianopsia  when  the 
nasal  half  of  each  field  is  defective,  or  heteronymous 
temporal  hemianopsia  when  the  loss  of  vision  is  con- 
fined to  the  temporal  half  of  each  retina.  The  dividing 
line  between  the  seeing  and  the  non-seeing  areas  may 
or  may  not  pass  through  the  fixation  point,  and  the 
blindness  may  be  partial  or  absolute — that  is,  the  hemi- 
anopsia may  be  complete  or  incomplete.  Since  the 
fields  of  vision  are  projected  from  the  opposite  sides  of 
the  retina,  it  is  evident  that  medial  hemianopsia  signi- 
fies blindness  of  the  temporal  half  of  each  retina,  and 
temporal  hemianopsia,  blindness  of  the  nasal  half. 
Either    variety    of    heteronymous    hemianopsia    indicates 


118         THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

an  affection  of  the  chiasm,  and  is  strongly  suggestive  of 
a  syphilitic  gumma,  for  gummous  meningitis  at  the  base 
of  the  brain  is,  next  to  endarteritis,  the  most  common 
form  of  brain  syphilis,  and  the  most  frequent  situation 
of  the  affection  is  in  the  immediate  vicinity  of  the 
chiasm.  Temporal  hemianopsia,  as  a  result  of  syphilis, 
occurs,  it  is  estimated,  twice  as  frequently  as  homony- 
mous hemianopsia  from  the  same  cause. 

In  medial  hemianopsia  the  uncrossed  bundles 
of  fibres  of  each  tract  are  affected,  and  therefore  the  le- 
sion is  to  be  located  at  the  outer  edge  of  the  chiasm 
on  either  side.  In  temporal  hemianopsia  the  lesion  in- 
volves the  crossed  bundles  of  each  tract,  and  it  can  only 
result  from  a  morbid  process  affecting  the  central  part 
of  the  chiasm  from  before  backward,  or  at  its  anterior 
or  posterior  angle.  Accumulation  of  fluid  in  the  third 
ventricle  with  hydrops  of  the  infundibulum  would 
exert  transverse  pressure  on  the  chiasm,  with  such  vis- 
ual manifestations. 

Homonymous  hemianopsia,  that  is,  a  loss,  more 
or  less  complete,  of  functionally  associated  and  corre- 
sponding portions  of  each  visual  field,  right  or  left,  can 
only  be  explained  by  a  lesion  affecting  the  fibres  of  one 
optic  tract,  and  this  may  be  situated  at  any  point  be- 
tween the  chiasm  and  the  cortex.  The  designation  of 
right  or  left  homonymous  hemianopsia,  it  will  be  under- 
stood, refers  to  field  and  not  to  retina.  The  pres- 
ence or  absence  of   the  light  reflex  and  of   visual  hallu- 


HEMIANOPSIA.  119 

cinations  (photopsia,  etc.)  is  of  importance  in  more  ex- 
actly locating  the  lesion.  The  optic  tract  may  be  com- 
pressed by  the  exudation  attending  basilar  meningitis, 
by  a  syphilitic  gumma  (the  most  frequent  cause)  or 
other  neoplasm,  or  by  a  hemorrhage.  It  is  evident  that 
since  visual  impressions  are  interrupted  in  the  affected 
tract,  sensory  reflex  iridoplegia  will  necessarily  result. 
There  will  be  no  contraction  of  the  pupils  when  light 
is  thrown  upon  the  blind  halves  of  the  retinae,  but  the 
light  reflex  will  be  preserved  when  the  light  is  thrown 
on  the  seeing  part  of  either  retina,  transmission  being 
uninterrupted  along  the  uninjured  tract. 

The  same  condition,  viz.,  "  hemianopic  pupillary 
inaction  "  is  present  in  homonymous  hemianopsia  due 
to  a  lesion  of  the  pulvinar,  and  in  the  absence  of 
involvement  of  the  nerves  supplying  the  ocular  muscles, 
and  other  phenomena  which  would  almost  of  necessity 
accompany  a  lesion  of  one  tract,  this  symptom  warrants 
a  diagnosis  of  a  lesion  at  this  point.  When  hemianopic 
visual  disorders  are  caused  by  disease  in  the  course  of 
the  optic  radiation,  or  in  the  cortical  visual  area,  the 
pupillary  light  reaction  is  preserved,  and  this  is  true 
whether  the  blind  or  the  seeing  portion  of  the  retina  is 
illuminated,  and  irrespective  of  any  conscious  sensation 
of  light.  Homonymous  hemianopsia  may  occur  suddenly 
as  the  sole  manifestation  of  a  cerebral  hemorrhage.  If, 
under  such  circumstances,  the  pupillary  light  reflex  is 
preserved,  the   presence   or   absence  of   visual   hallucina- 


120         THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

tions  may  enable  one  to  decide  whether  the  hemorrhage 
is  cortical,  or  situated  in  the  path  of  the  optic  radiation. 
If  the  visual  area  in  the  occipital  cortex  is  destroyed, 
there  can  be  no  photopsia  or  visual  hallucinations. 
Hence,  if  they  exist  in  the  affected  half  of  the  visual 
field  the  lesion  is  not  cortical,  but  when  they  are  want- 
ing, we  possess  no  data  for  exact  localization  in  one  or 
other  of  these  circumscribed  areas. 

Vialet,  of  Paris,  in  "Annates  d' Oculistique/'  Paris, 
April,  1894,  thus  defines  the  boundaries  of  the  cortical 
visual  area.  It  "occupies  the  entire  extent  of  the  in- 
ternal surface  of  the  occipital  lobe,  embracing  the 
cuneus  and  the  fusiform  lobes,  being  bounded  anteriorly 
by  the  internal  perpendicular  fissure  (parieto-occipital  ?), 
above  by  the  superior  edge  of  the  hemisphere,  below  by 
the  inferior  edge  of  the  third  occipital  convolution,  and 
behind  by  the  occipital   lobe." 

Different  portions  of  this  area  are  in  relation 
with  distinct  parts  of  the  field  of  the  opposite  eye. 
"  The  macular  region  corresponds  to  the  cuneus  and, 
perhaps,  to  the  first  occipital  convolution.  In  the  re- 
mainder of  the  occipital  cortex  known  as  '  NothnagePs 
memory  centre  for  visual  impressions,'  the  anterior  part 
corresponds  to  the  inferior  part  of  the  opposite  field,  the 
lateral  part  to  the  outer,  the  posterior  parts  to  the  up- 
per portions  of  the  field.  Hence  in  partial  destruction 
of   the    occipital    cortex,  the    visual    disturbance    varies 


CROSSED  AMBLYOPIA.  121 

greatly  according  to  the  location  of  the  diseased  focus." 
(Knies). 

There  seems  to  be  a  separate  centre  for  the  per- 
ception of  color,  for  hemianopsia  for  color  sometimes 
exists  without  other  defect.  The  apex  of  the  occipital 
lobe  is  the  spot  where  a  lesion  produces  most  complete 
and  pronounced  hemianopsia,  but  injuries  to  the  outer 
and  medial  surfaces  also  produce  this  defect  to  a  lesser 
degree,  manifested  as  "  hemianopic  peripheral  scotomata 
with  practically  no  subjective  sensations,  and  not  de- 
tected with  the  perimeter  without  great  care."  It  should 
be  borne  in  mind  that  cortical  lesions  are  always  ho- 
monymous, and  this  feature  will  aid  in  a  differential 
diagnosis  between  such  disorders  and  scotomata  and 
contractions  of  the  fields  due  to  affections  of  the  retina 
and  optic  nerve,  which  occur  in  the  course  of  cerebral 
tumors,  dementia  paralytica,  tabes,  etc. 

Defects  of  the  visual  field  without  ophthalmo- 
scopic findings  also  occur  in  hysteria  and  uraemia,  and 
the  reader  is  referred  to  the  chapter  on  reflex  neuroses 
for  a  discussion  of  such  disorders. 

CROSSED  AMBLYOPIA. 

It  would  seem  from  the  occurrence  of  crossed 
amblyopia,  that  is,  dimness  of  sight  in  the  opposite  eye, 
generally  with  concentric  diminution  of  the  field,  and 
with  some  restriction  of  the  field  on  the  same  side,  that 
there  is  a  higher  visual    centre  where  impressions   from 


J  22  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

both  fields  are  united.  There  have  been  a  few  recorded 
autopsies  of  cases  presenting  crossed  amblyopia  during 
life,  in  which  the  posterior  and  inferior  part  of  the 
parietal  lobe  known  as  the  "  angular  gyrus "  was  dis- 
eased. Thus  pathological  evidence  would  seem  to  point 
to  this  locality  as  the  seat  of  a  higher  visual  centre, 
'and  Ferrier  has  demonstrated  the  existence  of  such  a 
centre  at  this  spot  in  animals.  The  theory  of  crossed 
amblyopia  was  first  advanced  by  Charcot,  and  it  is  sup- 
ported by  Gowers  but  discredited  by  others. 

There  are  various  forms  of  transient  amblyopia 
which  can  only  be  explained  by  temporary  disorders  of 
the  circulation  in  the  visual  centres.  Such  transient 
amblyopia  may  be  manifested  as  hemianopic  defects, 
symmetrical  scotomata,  central  or  peripheral,  or  as  more 
or  less  complete  blindness  associated  or  not  with  scin- 
tillation, or  the  appearance  of  sparks  or  flashes  of  light. 
Such  attacks  appear  more  frequently  in  females,  and  in 
persons  of  neurotic  temperament.  They  are  explained 
by  a  vaso-motor  disturbance  in  the  visual  areas,  and  it 
is  important  to  understand  that  they  are  not,  as  a  rule, 
of  serious  import.  Occasionally  they  are  the  precursors 
of  an  epileptic  attack.  More  frequently  they  are  asso- 
ciated with  cephalalgia  and  vertigo. 

AMAUROSIS   AND   AMBLYOPIA.      PSYCHIC    VISUAL 
DISORDERS. 

Sudden  blindness  of  both  eyes  may  result  from  a 
simultaneous  affection  of  both  visual  areas.      Monocular 


PSYCHIC  VISUAL  DISORDERS.  123 

blindness  points  to  an  affection  of  the  optic  nerve  in 
front  of  the  chiasm,  or  to  an  intraocular  affection.  Cor- 
tical disorders,  it  will  be  remembered,  are  always  binoc- 
ular, and  are  attended  with  preserved  pupillary  reaction. 
Meningitis  of  the  convexity  of  the  brain  with  exudation 
may  occasion  such  loss  of  vision.  It  may  result  from 
extreme  loss  of  blood,  producing  anaemia  and  loss  of 
sensibility  of  the  visual  centres.  In  such  cases  the  vis- 
ion will  be  recovered  with  the  returning  circulation.  It 
may  be  due  to  malaria.  It  may  be  of  toxaemic  origin, 
especially  in  uraemia.  It  may  be  due  to  reflex  irrita- 
tion or  be  a  manifestation  of  hysteria.  The  visual  dis- 
orders associated  with  these  affections  are  discussed  in 
the  chapter  on  reflex  neuroses. 

The  opposite  condition,  viz.,  undue  excitability 
of  the  visual  centres  manifested  by  photophobia  and 
hyperaesthesia  of  the  retina,  phosphenes,  etc.,  unaccom- 
panied with  inflammatory  conditions  of  the  eye  may  be 
a  part  of  a  general  nervous  excitability,  or  may  be  an 
early  symptom  of  meningitis  or  encephalitis. 

There  will  be  no  difficulty  in  diagnosing  a  case 
of  sudden  blindness  due  to  uraemic  intoxication,  for  it 
is  always  associated  with  other  symptoms,  such  as  head- 
ache, vomiting,  stupor  and  convulsions.  It  is  caused  by 
an  affection  of  the  visual  centres  either  from  a  toxic 
element  in  the  blood,  or,  perhaps,  as  has  been  sug- 
gested, by  an  anaemia  consecutive  to  an  extensive  effu- 
sion into  the  cerebral  ventricles.      The   exact   pathology 


124  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

is  undetermined.  The  pupillary  reaction  to  light  is  or- 
dinarily preserved,  and  unless  complicated  with  a  pre- 
vious albuminuric  retinitis,  there  are  no  ophthalmoscopic 
changes,  and  the  sight  returns  with  the  subsidence  of 
the  other  uraemic  manifestations.  Uraemic  amaurosis  is 
said  to  occur  most  frequently  with  post-scarlatinal  neph- 
ritis, and  next  with  the  contracted  kidney,  and  it  is 
sometimes  met  with  in  the  nephritis  of  pregnancy. 
Similar  visual  disturbances  occasionally  appear  in  the 
later  stages  of  diabetes. 

It  remains  to  discuss  certain  psychic  visual  dis- 
orders. 

Hallucinations  of  sight,  that  is,  "false  inter- 
pretations and  judgments  of  real  sensorial  phenomena," 
are  an  indication  of  mental  disorders.  The  pupils  dilate 
or  contract  as  the  fancied  object  apparently  recedes  or 
approaches.  This  circumstance  may  be  of  use  in  the 
treatment  of  delirium  or  insanity.  Such  symptoms  are 
also  sometimes  of  toxic  origin.  See  chapter  on  toxic 
amblyopia. 

A  peculiar  and  interesting  form  of  visual  defect 
styled  by  Fuchs  "soul  blindness,"  sometimes  results 
from  a  diseased  focus  situated  in  the  vicinity  of  the 
localities  implicated  in  cases  of  hemianopsia  and  crossed 
amblyopia,  but  distinctly  separated  therefrom.  The  pa- 
tient sees,  but  he  has  lost  all  memory  of  visual  impres- 
sions, and,  therefore,  objects  are  unrecognized.  He  cannot 
read  because  he  has  lost  all  memory  of  the  meaning  of 


PSYCHIC  VISUAL  DISORDERS.  125 

the  characters  (alexia).  Or  he  may  recognize  objects, 
but  cannot  recall  their  names,  a  condition  constituting 
word  blindness. 

Soul  blindness  is  usually  a  transient  symptom 
associated  with  disease  of  another  portion  of  the  brain. 
Knies  says  that  it  is  very  rare  as  an  isolated  symptom, 
that  it  occurs  quite  often  with  progressive  paralysis 
of  the  insane,  but  is  always  temporary. 

An  interruption  in  the  course  of  the  commissural 
fibres  uniting  the  visual  areas  with  the  higher  intellect- 
ual centres  explains  another  interesting  class  of  psychic 
visual  disorders  which  may  be  briefly  mentioned,  viz.  : 

Motor  Alexia. — This  is  very  similar  to  soul 
blindness  and  word  blindness,  but  differs  from  those 
conditions  in  that  the  names  of  objects  seen  cannot  be 
spoken,  although  remembered. 

Dyslexia, — "  He  can  read  aloud,  but  after  utter- 
ing a  few  words,  a  peculiar  uncomfortable  feeling  is 
experienced  which  compels  him  to  stop.  This  condi- 
tion is  temporary,  but  often  followed  by  severe  cerebral 
symptoms." 

Paralexia. — A  condition  in  which  "  single  let- 
ters, syllables  or  words  are  omitted  in  reading  or  con- 
fused with  others  having  a  similar  sound." 

Agraphia. — '•  In  which  he  cannot  copy,  although 
the  movements  of  the  hand  and  arm  are  unimpaired 
and  he  can  write  from  dictation." 


126  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Paragraphia. — In  which  there  is  a  "  confusion 
or  omission  of  letters,  syllables  and  words  in  writing." 

Such  conditions  as  the  above  are  usually  transi- 
tory. The  precise  location  of  lesions  causing  them  can- 
not be  definitely  determined,  but  it  may  be  stated  that 
if  the  motor  or  visual  symptoms  are  the  more  pro- 
nounced, the  disease  is  located  nearer  the  motor  or  the 
visual  centres  respectively. 


CHAPTER  VI. 

A   TABULATED   STATEMENT   OF    DISEASES   WITH    MORE    OR 
LESS    CHARACTERISTIC   EYE   SYMPTOMS. 

ABDOMINAL  6B0WTHS. 

More  or  less  pigmentation  of  the  skin  of  the  eye- 
lids. 

ADDISON'S  DISEASE  OF  THE  SUPBA  BENAL  CAPSULES. 

Pigmentation  of  the  skin  of  the  lids  and  of  the 
sclera. 

ALBUMINTIBIA. 

Retinitis,  and  neuro-retinitis. 

ALCOHOLISM. 

Paretic  mydriasis.  Paralysis  of  accommodation, 
or  spastic  myosis  in  the  early  excitable  stage. 
Paralysis  of  the  external   ocular  muscles.     Ptosis. 

ANAEMIA  (CEBEBBAL). 

Paretic  mydriasis 

ANAEMIA  (CONSTITTTTIONAL). 

Paralysis  of  accommodation,  choroiditis,  retinitis 
and  retinal  hemorrhages. 

ANETJBISM  OF  OBBITAL  ABTEBT,  OB  INTEBNAL  CABOTID. 

Exophthalmus. 

AOBTA  AND  ABTEBIA  INNOMINATA,  ANETJBISM  OF. 

Reflex  spastic  mydriasis  on  the  side  of  the  lesion. 
Retinal  pulsation. 

(127) 


128         THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 
APOPLEXY. 

Dilatation  or  contraction  of  the  pupils  distin- 
guishes it  from  embolism,  in  which  the  pupils 
are  unaffected.  Spastic  myosis  in  premonitory 
stage.  When,  during  a  seizure,  mydriasis  occurs 
after  a  previous  myosis  it  is  an  unfavorable 
symptom,  signifying  increasing  pressure.  Nystag- 
mus.    Homonymous  hemianopsia. 

APOPLEXT  OF  COST  EX  OR  COBONA  RASIATA. 

Eyes  and  extremities  paralyzed  on  the  same  side. 
Eyes  deviate  toward  the  side  of  the  lesion. 

APOPLEXY  OF  THE  CEU8  OK  PONS  VAEOLII. 

Eyes  and  extremities  paralyzed  on  opposite  sides. 
Eyes  deviate  away  from  the  side  on  which  the 
lesion  exists. 

APOPLEXY  OF  THE  PONS. 

Spastic  myosis. 

APOPLEXY  OF  VENTSICLES. 

Spastic  myosis. 

ATHEBOMA. 

Conjunctival  hemorrhage.  Intra-ocular  hemor- 
rhages. 

ATBOPHY,  PBOOBESSIVE,  MUSCULAB. 

Ocular  paralyses. 

BASEDOW'S  DISEASE  OB  EXOPHTHALMIC  OOITBE. 

Diminished  frequency  of  winking.  Spasm  of  the 
levator  of  the  upper  lid.  (Abadie's  sign).  Widen- 
ing of  the  palpebral  fissure,  owing  to  contraction 
of    Mueller's    muscle.      (Stellwag's  or  Dalrymple's 


A  TABULATED  STATEMENT  OP  EYE  SYMPTOMS.  129 

sign).  Loss  of  associated  movement  of  the  upper 
lid  and  the  eye-ball.  (Von  Graefe's  sign).  Ex- 
ophthalmus. 

BRAIN,  ABSCESS  OF. 

Neuritis. 

BASILAB  AFFECTIONS  OF. 

Loss  of  pupillary  reflexes.  Homonymous 
hemianopsia.     Paralyses  of  ocular  muscles. 

'<         CEBEBBAL  CORTICAL  AFFECTIONS. 

Conjugate  ocular  paralyses,  (or  ophthalmo- 
plegias.) Loss  of  voluntary  movements  of 
the  eyes,  with  preservation  of  involuntary  or 
reflex  movements  of  pupil  and  eye-ball. 
Eyes  paralyzed  on  side  opposite  the  cerebral 
lesion.  Eyes  deviate  towards  side  of  lesion. 
Psychic  visual  disorders. 

"         CEREBRAL   AFFECTIONS  WITH    INCREASED    INTRA-CRANIAL 
PRESSURE. 

Paretic  mydriasis  ordinarily.  Sometimes 
reflex  spastic  mydriasis. 

"        CEREBELLUM,  AFFECTIONS  OF. 

Nystagmus. 

"         CONCUSSION  OF. 

Sluggish  action  of  pupils  without  marked 
dilatation  or  contraction. 

"         HYPERAEMIA  OF. 

Spastic  myosis. 

"        TUMOR  OF. 

Nystagmus.     Paretic  mydriasis.       Choked  disc. 

Choked    neuritis.       Atrophy    of    optic     ner\'e. 
9 


130         THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

Homonymous     hemianopsia,     when     pressure 
is  exerted  upon  fibres  of  one  tract 

CHOLEBA. 

Conjunctival  hemorrhage.  Anesthesia  of  cornea. 
Neuro-paralytic  keratitis.  Loss  of  the  light  reflex 
indicates  a  fatal  termination  even  in  apparently 
mild  cases.  Preservation  of  the  light  reflex  war- 
rants a  favorable  prognosis,  even  in  severe  cases. 
Black  patches  appear  in  the  sclerotic  below  the 
cornea  in  severe  cases.  They  are  of  irregular 
fonn  and  size  and  tend  to  coalesce.  Their  pres- 
ence is  of  very  unfavorable  significance. 

COMA,  ALCOHOLIC  OB  UBAEMIC. 

Mydriasis. 

COMA,  STPHILITIC. 

Myosis  and  reflex  iridoplegia. 

DEATH,  8ION8  OF. 

Opacity  and  insensibility  of  the  cornea.  Desicca- 
tion of  the  sclera.  Abolition  of  pupillar>'  reflexes. 
Absence  of  the  red  reflex  from  the  fundus. 

DEITTAL  AFFECTIONS. 

Various  forms  of  inflammation  of  the  cornea. 
Nictitation. 

DIABETES. 

Eczema  of  the  eyelids.  Conjunctival  hemorrhage. 
Ulceration  of  the  cornea.  Paralysis  of  the  exter- 
nal ocular  muscles  and  of  the  accommodation. 
Cortical    cataract.      Retinitis    and    neuro-retinitis. 


A  TABULATED  STATEMENT  OF  EYE  SYMPTOMS.  131 

Atiophy  of  the  optic  nen^e.  Degeneration  of  the 
retinal  vessels  and  hemorrhages.  Lagrange  found, 
in  52  cases  of  diabetes,  13  of  intra-ocular  hemor- 
rhage and  the  same  number  of  cases  of  cataract. 
(See  "Arch.  d'Ophth.,"  Jan.,  1887).  Galezowski 
found  in  144  cases  of  diabetes,  5  of  paresis  of 
accommodation,  4  of  keratitis,  7  of  iritis,  4  of 
glaucoma,  46  of  cataract,  27  of  retinitis,  31  of 
amblyopia,  3  of  amotio  retinae,  and  3  of  atrophy 
of  the  optic  nerve.  (See  "Jahr.  /.  Aug.,"  1883,  p. 
297). 

DIGESTION,  DISOBDEBS  OF. 

Styes.     Nictitation. 

DIPHTHEBIA. 

Diphtheritic  conjunctivitis.  Paralysis  of  the  ex- 
ternal eye  muscles  rare ;  of  accommodation  more 
frequent. 

EMBOLISM,  CEBEBBAL. 

No  pupillary  symptoms ;  in  contradistinction  from 
apoplexy. 

EPILEPSY. 

Paretic  mydriasis  during  the  seizure  or  spastic 
myosis.  Hippus  as  consciousness  returns  and  fre- 
quently during  the  intervals.  Spasms  of  the  ocu- 
lar muscles. 

FEVEB,  PTIEBPEBAL  AND  TYPHOID. 

Metastatic  suppurative  choroiditis. 

PEVEB,  BELAPSING. 

Iritis. 


182  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

FIFTH  NERVE,  AFFECTIONS  OP. 

Reflex  spastic  myosis. 

FOUBTH  VENTRICLE,  LESIONS  IN. 

Nuclear  ocular  paralyses   affecting  separate  nuclei 

of   the    third    nerve,  or  successive  implication   of 

its  various  branches.  Also  total  paralysis  of  all 
the  muscles  of  both  eyes. 

FRIEDREICH'S  DISEASE  (HEREDITARY  ATAXIA). 

Nystagmus. 

OOUT. 

Retinitis. 

HEART,  AORTIC  INSUFFICIENCY. 

Alternate   reddening  and  pallor  of   the  optic  disc. 

HEART,  ENDOCARDITIS. 

Embolism  of  the  arteria  centralis  retinae. 

HEART,  ORGANIC  AFFECTIONS  OF. 

Oedema  of  lids.  Venous  hyperaemia  of  retina 
and  pulsation  of  retinal  arteries.  Seen  with  val- 
vular affections,  fatty  heart  and  aortic  insuffi- 
ciency. 

HEART,  HYPERTROPHY  OF  LEFT  VENTRICLE. 

Retinal  hemorrhages. 

HEART,  VALVULAR  LESIONS  OF. 

Retinal  hemorrhages. 

HELMINTHIASIS. 

Reflex  spastic  mydriasis. 

HEPATIC  AFFECTIONS. 

Pigmentation  of  the  skin  of  the  lids.  Coloration 
of  sclera. 


A  TUBULATED  STATEMENT  OF  EYE  SYMPTOMS.  133 

HYDEAEMIA. 

Oedema  of  lids. 

HYOBOCEFHALTJS. 

Paretic  mydriasis.  Neuritis  and  atrophy  of  optic 
nerve. 

HYSTEEIA. 

Chromidrosis.  Epiphora.  Ptosis.  Spastic  myosis 
(during  a  hysterical  convulsion).  Hippus.  Hyper- 
aesthesia  of  the  retina.  Spasm  of  accommodation. 
Amblyopia.  Contraction  of  the  visual  field.  Sud- 
den onset,  erratic  course,  sudden  disappearance. 

INSANITY. 

Monocular  mydriasis  and  paralysis  of  accommoda- 
tion are  suspicious  premonitory  signs,  as  is  also 
transient  recurrent  mydriasis. 

KIDNEY,  DISEASES  OF. 

Degeneration  of  the  retinal  vessels  with  or  with- 
out hemorrhages.  Retinitis  and  neuro-retinitis. 
Amblyopia.     Oedema  of  lids. 

LEPROSY. 

Leprous  nodules  in  eyelids,  conjunctiva,  cornea 
and  iris.  Anaesthetic  spots  and  white  patches  in 
the  lids.  According  to  Lopez  ("Archiv.  /.  Aug.," 
XXII,  2  and  3)  "the  eye  is  affected  in  half  the 
cases,  the  eye  with  its  appendages  in  all  cases." 
Knies. 

LUNG,  DISEASE  OF  APEX. 

Reflex  spastic  mydriasis. 


134  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

MALABIA. 

Chronic  superficial  non-siippurative  keratitis.  Sen- 
sitiveness of  supra-orbital  nerves.  Retinal  hemor- 
rhages.    Choroiditis. 

MANIA. 

Reflex  spastic  mydriasis. 
kastubbation. 

Paralysis  of  accommodation.  Hyperaesthesia  of 
the  retina. 

MELANCHOLIA. 

Reflex  spastic  mydriasis. 

MENINGITIS,  CEBEBBAL. 
'•        ACUTE. 

Mydriasis  or  myosis.  Photophobia.  Injec- 
tion of  conjunctiva. 

"        CHBONIC. 

Interstitial  and  peri-neuritis.  Atrophy  of  the 
optic  nerve. 

"        OF  THE  CONVEXITY. 

Cortical  blindness  or  hemianopsia  with  pre- 
served pupillary  light  reflex.  Hyperaesthesia 
of  the  retina.     Photophobia,  phosphenes,  etc. 

"        CEBEBBO-SPINAL. 

Eye  symptoms  frequent.  Conjunctivitis  in 
early  stages.  Later  oedema  of  conjunctiva, 
denoting  exudation  in  cranial  cavity.  Stra- 
bismus. Nystagmus.  Spastic  myosis  in  early 
stages.  Reflex  spastic  mydriasis  from  pinch- 
ing   the    skin    at    the    back     of     the    neck. 


A  TUBULATED  STATEMENT  OF  EYE  SYMPTOMS.  135 

(Parrot's  sign).  Hippus.  Choroiditis.  Photo- 
phobia.    Neuritis. 

MENINGITIS,  SPINAL. 

Spastic  mydriasis  in  the  early  stage. 

"   TUBERCULAR. 

Strabismus.  Nystagmus.  Ocular  paralyses. 
Spastic  myosis  in  early  stage.  Rapid  alter- 
nation of  myosis  and  mydriasis.  Paretic 
mydriasis  in  later  stages  in  contra-distinction 
from  cerebro-spinal  meningitis,  in  which  it 
is  rare.  Tuberculosis  of  the  choroid.  Homo- 
nymous hemianopsia. 

MENINGEAL  HEMORRHAGE. 

Nystagmus.     Hemianopsia. 

MENSTRUATION,  DISORDERS  OF. 

Styes. 

MYELITIS,  ACUTE  AND  CHRONIC. 

Neuritis  or  simple  atrophy  of  the  optic  nerve. 

MYXOEDEMA. 

Thickening  and  swelling  of  the  lids. 

NEPHRITIS. 

See  diseases  of  the  kidney. 

NEURALGIA  OF  THE  FIFTH  NERVE. 

Paralysis  of  accommodation. 

NEURITIS,  MULTIPLE  OR  PSEUDO-TABES. 

Axial  neuritis  with  central  scotoma.  Absence  of 
pupillary  symptoms,  in  contra-distinction  from 
true  tabes. 


136         THE   EYE   AS   AN   AID   IN  GENERAL   DIAGNOSIS. 
NICOTINE  POISONING. 

Spastic  myosis.  Retro-bulbar  neuritis  with  central 
scotoma. 

FABALTSIS. 

•'        AOITANS. 

Tremor  of  the  lids.     Ptosis. 

"       GENERAL  (PAEALT8I8  OF  INSANE.    PARESIS) . 

Monocular  mydriasis  and  paralysis  of  the 
accommodation  and  transient  recurrent  myd- 
riasis are  suspicious  premonitory  symptoms. 
Paretic  mydriasis  is  an  early  symptom.  The 
"Argyll-Robertson  pupil "  is  found  in  fifty 
per  cent,  of  the  cases.  Anisocorea.  Paretic 
myosis.  Optic  neuritis.  Atrophy  of  optic 
nerve.  Soul  blindness.  Sudden  development 
and  transient  duration  of  ocular  symptoms, 
similar  to  multiple  sclerosis  and  tabes. 

POLIO    ENCEPHALITIS    SUPERIOR    (INFLAMMATION    OF    THE    FLOOR 
OF  THE  FOURTH  VENTRICLE). 

Progressive  paralysis  of  the  ocular  muscles  is  the 
essential  feature. 

PONS  VAROLII,  LESIONS  OF. 

Nystagmus.  Associate  ocular  paralyses  in  hori- 
zontal lines.  Spastic  myosis.  An  isolated  lesion 
of  one  side  produces  paralysis  of  the  external 
rectus  on  the  same  side. 

PYAEMIA. 

Metastatic  suppurative  choroiditis.  Retinal  hemor- 
rhages. 


A  TUBULATED  STATEMENT  OF  EYE  SYMPTOMS.  137 

EACHITIS. 

Cortical  or  laminated  cataract. 

SHEUBTATISM. 

Paralysis  of  external  ocular  muscles,  usually  of 
one  eye,  and  affecting  one  or  more  contiguous 
branches  of  the  nerve,  such  as  the  superior  rectus 
and  levator  palpebrae  superioris.  Iritis  with  gela- 
tinous exudation. 

SCLEBOSIS,  MULTIPLE. 

Nystagmus,  a  frequent  and  valuable  diagnostic 
sign.  Ocular  paralyses  characterized  by  sudden 
development,  transient  duration  and  variable 
course,  similar  to  syphilis  and  tabes.  Hippus. 
Paralysis  of  accommodation.  Impairment  of  vis- 
ion, but  rarely  complete  blindness.  Central  sco- 
toma. Irregular  or  concentric  contraction  of  the 
visual  field.     Neuritis. 

SCKOFULA. 

Eczema  of  lids.  Styes.  Ciliary  blepharitis.  Con- 
junctivitis. Pustules  and  abscesses  of  the  cornea. 
Phlyctenular  conjunctivitis  and  keratitis.  Choroi- 
ditis. 

SNAKE  POISONING. 

Retinal  hemorrhages. 

SKIN,  EXTENSIVE  BURNS  OF. 

Reflex  spastic  mydriasis  (skin  reflex). 

SPINAL  COBD. 

"       INFLAMMATION  AND   CONGESTION  OF.    SPINAL  IRBITATION. 

Spastic  mydriasis  occurs  in  the  early  stages. 


138         THE   EYE   AS  AN   AID   IN   GENERAL   DIAGNOSIS. 
SPINAL  COSD,  DE6ENEBATIVE  DISEASE  OF. 

Nystagmus. 

8TFHILIS. 

Every  tissue  of  the  eye,  except  the  lens,  is  af- 
fected. Inflammations  of  the  lids,  orbit  and  ly- 
chrymal  passages.  Arrest  of  development,  such 
as  microphthalmus,  etc.,  in  the  congenital  form. 
Periostitis  and  caries  of  the  orbit.  Paralytic  af- 
fections of  the  lids  and  external  ocular  muscles. 
Various  muscles  are  suddenly,  successively  and 
transiently  involved.  Parenchymatous  keratitis. 
Inflammation  of  the  sclera  with  gummata.  Myd- 
riasis with  loss  of  accommodation.  Gummous 
iritis.  Choroiditis.  Degeneration  of  the  retinal 
vessels  with  or  without  hemorrhages.  Retinitis 
and  neuro-retinitis.  Atrophy  of  the  optic  nerve. 
Heteronymous  and  homonymous  hemianopsia. 
Zimmerman,  of  Milwaukee,  says,  in  "  Knapp's 
Archives,"  Jan.,  1895,  that  only  about  15  per 
cent,  of  the  cases  of  brain  syphilis  are  without 
ocular  symptoms. 

TABES. 

Anaesthesia  of  the  skin  of  the  lids  of  the  con- 
junctiva and  cornea,  with  false  localization  of 
sensation.  Paresis  of  orbicularis  palpebrarum. 
Narrowing  of  the  palpebral  fissure.  Ptosis.  Pa- 
ralysis of  the  ocular  muscles,  sudden  in  develop- 
ment and    transient  in  duration,  similar  to  syphi- 


A  TUBULATED  STATEMENT  OF  EYE  SYMPTOMS.  139 

letic  paralyses  and  to  those  which  occur  in  mul- 
tiple sclerosis. 

Spastic  mydriasis  may  be  a  premonitory  symptom. 
Paretic  myosis  occurs  in  23  per  cent,  of  the  cases. 
The  "Argyll-Robertson  pupil "  is  a  very  character- 
istic symptom  and  occurs  in  70  per  cent,  of  the 
cases.  In  25  per  cent,  it  is  an  early  symptom. 
Reflex  iridoplegia,  or  failure  of  all  the  pupillary 
reflexes.  The  reaction  to  light  fails  first,  followed 
by  loss  of  reaction  with  accommodation  and  con- 
vergence, and  lastly  the  skin  reflex  is  lost. 
Anisocorea  occurs  in  34  per  cent,  of  the  cases. 
Reflex  iridoplegia  is  a  valuable  diagnostic  point 
between  true  and  false  tabes,  or  multiple  neuritis. 
In  the  latter,  myosis  and  reflex  iridoplegia  are 
wanting.  Atrophy  of  the  optic  nerve. 
Ocular  symptoms  may  appear  very  early,  even 
many  years  before  the  ataxic  symptoms.  Gowers 
relates  a  case  where  twenty  years  elapsed  between 
blindness  optic  nerve  atrophy,  etc.,  and  the  onset 
of  ataxia. 

WJien  spinal  symptoms  are  well  marked  ocular  symp- 
toms are  often  latent  or  absent,  and  the  reverse  is  also 
true,  viz.,  when  ocular  symptoms  are  marked  the 
spinal  symptoms  are  slight  or  absent  and  may  be  long 
delayed. 

TBICHINOSIS. 

Oedema  of  the  lids  and  paralysis  of  accommoda- 
tion. 


140  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

TUBEECULOSIS. 

Periostitis  and  caries  of  the  orbit.  Tubercular 
nodules  in  eyelids,  conjunctiva,  iris  and  choroid. 
Iritis  with  grayish-red  nodules. 

TTPHOID  FEYEB. 

Anaesthesia  of  the  cornea,  neuro-paralytic  kerati- 
tis. Hippus  in  stage  of  cerebral  manifestations. 
Metastatic  suppurative  choroiditis.  Intra-ocular 
hemorrhages. 

UBAEKIA. 

Mydriasis  is  a  premonitory  sign.  Sudden  failure 
of  vision. 

VTEBIHE  AFFECTIONS. 

Pigmentation  of  the  skin  of  the  lids.  Paralysis 
of  accommodation. 

UBTICABIA. 

Reflex  spastic  mydriasis 


PART  SECOND. 


REFLEX   NEUROSES 


(141) 


CHAPTER  VII. 

THE    RELATION  OF  OCULAR  AFFECTIONS  TO   FUNCTIONAL 
NERVOUS   DISEASES. 

The  term  neurosis  may  be  used  synonymously 
with  a  functional  nervous  affection.  By  either  expres- 
sion we  understand  a  disorder  of  the  nerves,  or  nerve 
centres,  of  a  purely  functional  nature,  and  unassociated 
with  known  organic  structural  changes.  It  is  not  as- 
serted that  such  changes  may  not  exist,  but  that  they 
have  not  been  recognized.  A  functional  nervous  disease 
may  originate  in  some  irritation  or  lesion  in  a  part  dis- 
tant from  that  in  which  the  symptoms  are  manifested. 
In  such  a  case  the  disease  is  designated  as  a  reflex  neu- 
rosis, and  the  reflex  influence  of  affections  of  the  eye  in 
causing  functional  nerv^ous  diseases  is  the  theme  of  the 
present  chapter.  The  converse  of  this,  viz.  :  the  discus- 
sion of  reflex  neuroses,  as  they  are  manifested  by  func- 
tional eye  diseases  dependent  upon  distant  foci  of  irri- 
tations, will  be  reserved  for  subsequent  consideration. 

Functional  nervous  diseases  may  be  conveniently 
classified  as  general  and  local.  In  the  former  class  be- 
long epilepsy,  chorea,  neurasthenia  and  hysteria.  Very 
much  has  been  written  during  the  past  few  years  upon 
the  relation  of  eye-strain  to  such  affections,  and  the  ten- 

(143) 


144  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

dency  of  specialism  in  medicine  to  beget  narrowness  of 
view,  and  of  enthusiastic  study  in  one  direction  to  dis- 
tort the  judgment  is  nowhere  more  clearly  exemplified. 
Mere  coincidence  has  been  many  times  mistaken  for 
cause  and  effect.  The  origin  of  almost  all  nervous  af- 
fections has  been  assigned  by  some  over-zealous  ophthal- 
'mologists  to  ocular  disorders,  and  the  exaggerated  im- 
portance thus  given  them  has  been  denied  by  others, 
some  of  whom  undoubtedly  underrate  their  influence  in 
such  directions.  The  truth,  as  I  shall  endeavor  to  show, 
lies   between   these   two   extreme   views. 

The  study  of  neuroses  is  one  of  great  import- 
ance, and  whatever  promises  to  extend  our  knowledge 
of  their  causes,  and  thus  to  teach  us  how  to  prevent 
their  development,  or  on  the  other  hand,  offers  additional 
means  of  cure  is  of  direct  value  and  merits  careful  con- 
sideration. The  recorded  observation  and  experience  of 
multitude  of  skilled  and  trustworthy  physicians  seem 
to  demonstrate  that  ocular  affections  are  both  a  cause 
and  an  effect  of  functional  nervous  diseases. 

The  wear  and  tear  of  modem  life  consequent 
upon  the  competition  of  business,  the  feverish  excite- 
ment and  anxiety  of  speculation,  the  demands  of  social 
and  fashionable  life  with  its  mental  and  physical  ex- 
haustion, the  excitement  of  modern  fiction  and  the 
drama,  are  some  of  the  universally  recognized  exciting 
causes  of  such  diseases.  Thus  an  inherited  neurotic 
temperament    transmitted  from  parent  to  child    is  a  fre- 


FUNCTIONAL  NERVOUS  DISEASES.  145 

quent  predisposing  cause,  and  the  extreme  and  increas- 
ing prevalence  of  nervous  disorders  is  thus  readily  un- 
derstood. When  a  person  of  this  neurotic  temperament, 
hereditary  or  acquired,  is  subjected  to  any  special  source 
of  nervous  exhaustion  the  effect  of  such  strain  is  inten- 
sified, and  is  followed,  in  many  instances,  by  pronounced 
and  far-reaching  effects.  The  fact  that  such  overwork, 
anxiety,  loss  of  sleep,  and  so  forth  is  often  well  borne 
without  obvious  injury  by  persons  in  robust  health  is 
no  proof  of  the  incorrectness  of  this  statement.  Simi- 
larly, any  organ,  although  somewhat  crippled  by  reason 
of  structural  weakness  or  difficult  or  painful  exercise 
of  function,  may  do  its  work  without  apparent  detriment 
when  the  body  as  a  whole  is  in  a  condition  of  perfect 
health,  but  when  the  vital  powers  are  enfeebled  from 
any  cause,  such  as  lack  of  nutrition,  overwork  bodily 
or  mental,  or  from  actual  disease,  the  weak  organ  is  the 
first  to  suffer  and  the  slowest  to  recover. 

We  recognize  in  certain  functional  eye-diseases 
both  the  cause  and  the  effect  of  general  neuroses  such 
as  those  enumerated.  The  faculty  of  vision  is  a  most 
complex  one,  demanding  the  exercise  of  various  and  in- 
tricate nervous  activities.  The  first  requisite  for  binocu- 
lar single  vision  is  that  an  image  of  the  object  shall 
be  formed  upon  corresponding  portions  of  each  retina. 
Otherwise,  the  two  retinal  impressions  cannot  be  blend- 
ed   into    a    harmonious    single    perception,    and    diplopia 

results.      In  order    that    the    images    mav   fall  upon  cor- 
10 


146  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

responding  retinal  points,  the  functional  integrity  of 
the  four  recti  and  the  two  oblique  muscles,  by  which 
the  harmonious  associated  movements  of  the  two  eyes 
are  obtained,  is  essential.  This  means  uninterrupted 
and  harmonious  inner\^ation  along  the  lines  of  the 
third,  fourth  and  sixth  nerves,  proceeding  from  physio- 
logically intact  centres,  which  preside  over  and  regulate 
the  ocular  movements.  The  normal  exercise  of  the 
faculty  of  accommodation  is  also  essential  to  perfect 
vision,  as  well  as  the  movements  of  the  iris,  calliug  for 
exercise  of  other  fibres  of  the  third  and  of  the  sympa- 
thetic nerves.  Supposing  these  factors  to  be  physiologi- 
cally and  anatomically  perfect,  and  the  dioptric  media 
to  be  transparent  and  of  proper  refractive  power,  the 
conduction  of  visual  impressions  through  the  optic 
nerve  must  be  unimpaired,  and  the  visual  centres  must 
be  in  healthy  condition,  in  order  that  the  impressions 
thus  received  may  be  converted  into  intelligent  percep- 
tions of  form,  size  and  color,  and  that  accurate  concept- 
ions of  the  nature,  distance  and  position  of  objects  may 
be  obtained.  When  we  remember  that  during  all  our 
waking  hours  the  eyes  are  in  constant  use  in  both  dis- 
tant and  near  vision,  and  when  we  consider  the  close  ap- 
plication required  of  the  student,  the  artist,  the  profes- 
sional man,  the  book-keeper  and  the  skilled  mechanic,  we 
are  in  a  position  to  realize  the  amount  of  nervous  energy 
which  is  thus  called  for,  and  to  appreciate  the  strain 
resulting  from  any  abnormality  of  structure  or  function 


FUNCTIONAL  NERVOUS  DISEASES.  147 

in  the  visual  apparatus,  and  the  influence  which  such  a 
strain  exerts  in  the  development  and  maintainance  of 
functional  neuroses  in  persons  of  neurotic  temperament. 
In  all  such  cases,  it  should  be  remembered  that  eye- 
strain is  an  important  factor  to  be  considered. 

OCULAR  AFFECTIONS  AS  A  CAUSATIVE 
INFLUENCE   IN   EPILEPSY. 

The  literature  of  the  past  few  years  contains  fre- 
quent references  to  the  subject,  and  many  cases  have 
been  reported  in  which  cures  have  followed  correction 
of  refractive  or  muscular  anomalies  of  the  eyes.  Doubt- 
less errors  in  diagnosis  have  sometimes  been  made,  and 
in  other  instances  sufficient  proof  of  recovery  has  not 
been  oflfered;  nevertheless  the  testimony  of  so  many  in- 
vestigators, many  of  them  men  of  recognized  ability  and 
trustworthiness,  is  deservdng  of  careful  consideration. 
Leaving  out  of  the  question  those  cases  of  epilepsy  con- 
secutive to  injuries  of  the  skull,  or  associated  with  or- 
ganic brain  disease,  there  remain  many  others  of  so- 
called  "  idiopathic  epilepsy "  in  which  no  pathological 
changes  have  been  discovered.  These  cases  occur  in 
persons  of  a  strongly  neurotic  temperament,  with  whom 
there  is  often  a  family  history  of  previous  epilepsy  or 
insanity.  Inherited  syphilis  often  exists  in  these  individ- 
uals with  defective  development  of  the  brain.  The  latter 
however  may  exist  without  syphilis,  and  be  the  result 
of  other  influences.     The  remote  cause,  viz.,  the  constitu- 


148  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

tional  predisposition  thus  induced,  is  of  vastly  more  im- 
portance than  the  exciting  cause.  The  latter  is  often 
apparently  insignificant  and  frequently  overlooked.  It 
may  be  dental  irritation,  helminthiasis  or  other  intesti- 
nal disorder,  or  a  reflex  influence  from  sexual  or  other 
nervous  excitation.  Frequently  it  is  some  strong  men- 
tal impression,  such  as  fright,  excitement  or  sudden 
grief.  These  conditions  alone  are  incapable  of  originat- 
ing true  epilepsy,  but  they  are  all  recognized  as  ade- 
quate exciting  causes  of  the  disease  when  added  to  a 
pronounced  predisposition  to  epilepsy.  Any  one  of  them 
may  on  an  appropriate  occasion  serve  as  a  match  to 
fire  an  explosion  of  nervous  energy  resulting  in  a  con- 
vulsive seizure.  A  repetition  may  occur  from  the  same 
or  a  similar  cause,  and  the  susceptibility  of  the  individ- 
ual increases  with  each  attack  until  they  recur  without 
assigna:ble  cause,  and  thus  true  idiopathetic  epilepsy  is 
developed.  A  single  convulsive  seizure  directly  due  to 
a  reflex  irritation,  as  in  children  during  dentition,  or 
with  acute  indigestion,  may  strongly  resemble  true  epi- 
lepsy, but  in  the  absence  of  repetition  could  hardly  be 
so  diagnosed.  If  a  transient  condition  such  as  those 
mentioned,  or  a  violent  fit  of  anger  or  fear  may  thus 
become  the  exciting  cause  of  convulsive  attacks  which 
continue  to  recur  without  the  repetition  of  the  initial 
cause,  it  seems  much  more  plausible  to  assign  a  causa- 
tive influence  to  a  perriianently  active  source  of  nerve 
waste  such  as  is  found  in  eye-strain,  and  it  is  a  signifi- 


FUNCTIONAL  NERVOUS  DISEASES.  149 

cant  fact  that  Semeling  ("  Charite  Annal.,''^  XI,  p.  389) 
asserts  that  anomalies  of  the  e5'^e  occur  in  20  per  cent, 
of  all  epileptics. 

Another  argument  in  support  of  the  influence  of 
eye-strain  is  afforded  by  the  fact  that  visual  aurae  pre- 
cede an  attack  in  a  large  number  of  cases  of  epilepsy. 
Gowers  says,  ("  Diseases  of  the  Nervous  System,"  Vol. 
2,  p.  739) :  "A  visual  warning  is  twice  as  frequent 
as  all  the  other  special  sense  aurae  together.  It  may 
be  a  sudden  loss  of  sight,  but  is  more  frequently  a 
visual  sensation,  a  flash  of  light  or  sparks,  or  flashes  of 
color.  Usually  many  colors  are  seen,  red  and  blue  most 
frequently.  It  may  be  an  elaborate  sensation,  a  vague 
beautiful  vision,  or  a  definite  image  of  some  object,  for 
instance,  an  old  woman  with  a  dress  of  some  certain 
color,  ugly  faces,  animals,  etc." 

An  aura,  either  sensory  or  motor,  "gives  us  in- 
formation of  the  functional  region  of  the  brain  where 
the  process  of  the  fit  begins,"  and  such  visual  aurae 
as  enumerated  clearly  indicate  that  in  many  cases  the 
visual  centre  is  the  locality  where  the  "  discharge "  com- 
mences. Aural  warnings  associated  with  the  sense  of 
vision,  or  of  varied  nature  and  location  are  more  common 
in  epilepsy  associated  with  organic  cerebral  lesions  than 
in  the  idiopathic  variety,  and  they  do  not  usually  indi- 
cate an  ascending  irritation  from  the  part  where  the  pe- 
culiar sensation  is  felt,  but  are  rather  the  expression  of  a 
central  irritation  referred   to  the  extremity  first  affected. 


160  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Clinical  experience  teaches  that  the  converse  may  be 
true  viz.,  that  peripheral  ascending  irritation  is  some- 
times the  cause  of  the  attack.  Gowers  mentions  a  case 
which  illustrates  this  fact.  A  boy  received  a  severe  cut 
on  one  of  the  fingers  of  the  right  hand  which  was  fol- 
lowed by  epilepsy.  The  spasms  always  commenced  in 
the  hand  and  were  arrested  by  amputation  of  the  in- 
jured finger. 

Visual  aurae  may  be  indirectly  dependent  upon 
eye-strain,  and  the  cure  of  epilepsy  by  correction  of  oc- 
ular anomalies  is  explained,  as  in  the  above  case,  by 
the  removal  of  the  cause  of  peripheral  irritation.  The 
path  by  which  such  influence  travels  from  the  eye  to 
the  brain  is  uncertain,  but  the  hypothesis  that  anae- 
mia of  the  brain,  due  to  vaso-motor  spasm,  is  the  im- 
mediate cause  of  the  explosion  of  nervous  energy  mani- 
festing itself  by  the  epileptic  crisis,  would  afford,  if 
proved,  a  probable  explanation  of  the  path  of  the  ocular 
reflex  through  the  intimate  connection  of  the  cerebral 
and  sympathetic  nerves  which  exists  in  and  around  the 
eye,  and  their  mutual  physiological  and  pathological  rela- 
tions. 

Much  time  and  space  might  be  occupied  in  quot- 
ing from  various  authors  reports  of  cases  of  epilepsy 
dependent  upon  eye-strain  and  cured  by  removal  of  the 
same.  D'Abundo  claims  to  have  cured  it  by  correction 
of  astigmatism.  Elliot,  Colburn  and  Frothingham  by 
convex    glasses,  and    Stevens   by  operative    measures   in 


FUNCTIONAL  NERVOUS  DISEASES.  •  151 

heterophoria.  Wood  says  in  a  discussion  of  the  "  Treat- 
ment of  Epilepsy  by  Tenotomy  of  the  Ocular  Muscles," 
in  the  "  New  York  Med.  Journal "  of  July  7  and  14,  1894: 
"Anomalies  of  the  muscles  alone  may  produce  epilepsy 
by  acting  as  a  reflex  irritant.  It  is  true  that  some 
cases  of  epilepsy  are  cured  by  muscular  treatment  when 
there  is  true  heterophoria.  In  cases  in  which  epilepsy 
is  to  be  attributed  to  loss  of  ocular  equilibrium,  other 
symptoms  of  the  latter  are  not  wanting".  Pechdo, 
Fumagalli  and  Galezowski  report  cures  by  enucleation. 
It  is  proper  to  remark  in  this  connection  that  cases  of 
epilepsy  have  been  cured  by  a  variety  of  trivial  opera- 
tive measures  where  the  results  must  be  attributed  to 
the  influence  of  suggestion.  After  making  due  allow- 
ance for  such  influence  and  for  too  enthusiastic  opin- 
ions, and  for  errors  of  judgment  and  of  diagnosis,  many 
cases  remain  too  well  authenticated  to  admit  of  doubt. 

If  the  preceding  arguments  are  worthy  of  consid- 
eration, a  single  case  will  carry  as  much  weight  as 
many  in  establishing  the  possibility  of  such  a  cause  for 
epilepsy,  and  of  emphasizing  the  importance  of  exam- 
ining the  eyes  in  all  cases  where  the  cause  and  the 
remedy  are  not  apparent.  If  this  most  serious  and  fre- 
quently incurable  disease  can  thus  be  relieved  even  oc- 
casionally we  shall  be  guilty  of  criminal  neglect  if  we 
omit  such  examination.  Dr.  F.  Park  Lewis,  in  the 
"  Eye,  Ear  and  Throat  Journal "  for  January,  1895, 
reports   the   following    case  of  epilepsy   dependent  upon 


152  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

eye-strain :  "  A  bright  young  man  of  eighteen  or  there- 
abouts, was  sent  about  two  years  ago  to  a  military  school 
where  he  was  successful  in  his  examinations  and  greatly 
interested  in  his  work.  The  amount  of  mental  work 
required  was  rather  unsual,  however,  and  the  discipline 
rigid.  Without  any  warning,  he  was  one  day  taken 
with  a  genuine  epileptic  seizure.  This  was  shortly  fol- 
lowed by  another  and  again  another,  so  that  it  was 
necessary  for  him  to  return  home.  He  was  placed 
under  the  care  of  a  prominent  neurologist  and  treated 
generously  with  bromides.  In  spite  of  care  and  treat- 
ment, the  attacks  decreased  neither  in  frequency  nor 
severity,  until  his  parents,  having  heard  of  eye-strain  as 
a  possible  cause  of  convulsions  of  this  character,  brought 
him  to  me  that  he  might  have  a  comprehensive  ocular 
examination.  Tests  under  atropine  showed  a  small  de- 
gree of  hypermetropia  with  a  quarter  of  a  dioptre  of 
vertical  astigmatism.  He  had,  however,  marked  esopho- 
ria  with  weakness  of  the  external  recti.  He  was  given 
appropriate  prisms,  operative  measures  being  held  in  re- 
serve. Surgical  interference  has  never  been  resorted  to, 
and  from  the  time  of  wearing  glasses  until  now — about 
a  year  ago — he  has  never  had  an  attack." 

Dr.  Lewis  remarks :  "  Other  cases  of  like  charac- 
ter might  be  given  in  which  high  degrees  of  exophoria 
and  also  astigmatism  have  been  the  exciting  causes  of 
epilepsy.  In  one  instance,  whenever  the  accommodation 
was  relaxed    with  atropine,  all   convulsive   tendency  im- 


FUNCTIONAL  NERVOUS  DISEASES.  153 

mediately  disappeared  and  did  not  return  while  the  my- 
driasis was  maintained To    fail   to 

recognize  the  reflex  nature  of  these  cases  is  to  shut  our 
eyes  in  the  only  direction  from  which  we  may  confi- 
dently look  for  relief.  The  fact  that  all  epilepsies  have 
not  a  reflex  origin,  or  the  equally  palpable  truth  that 
muscular  insufficiencies  and  other  nerve  strains  exist 
without  causing  disturbances,  either  epileptic  or  other- 
wise, is  no  argument  against  the  conclusion  that  I  have 
drawn,  and  only  leads  to  a  plea  for  a  more  careful  dif- 
ferentiation of  symptoms  and  their  probable  cause  in 
diagnosis,  and  a  greater  hesitancy  in  resorting  to  bro- 
mides or  any  palliative  measures  which  may  be  of 
doubtful  efficacy  in  the  one  set  of  cases,  and  must  be  of 
positive  injury  in  another  more  complicated,  and  less 
easy  to  diagnose  epileptic  group." 

Various  eye  symptoms  have  been  noticed  during 
an  epileptic  attack,  such  as  spasm  of  the  orbicularis 
and  deviation  of  both  eyes  toward  one  side,  and  roll- 
ing movements.  The  lids  may  be  open  or  closed, 
and  the  conjunctiva  is  insensitive.  The  pupils  may  be 
contracted  at  the  beginning  of  the  attack,  but  this  is 
not  invariable.  Dilatation  with  inaction  to  light  comes 
on  simultaneously  with  the  cyanosis,  and  continues  until 
signs  of  consciousness  begin  to  be  manifested,  when  the 
mydriasis  ceases.  Afterwards  there  is  alternate  contrac- 
tion and  dilatation,  changing  every  few  seconds  during 
an  interval    of    several  minutes.      Frequently  in   the  in- 


154  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

terim  between  attacks  there  occur  variations  in  the  size 
of  the  pupils  without  apparent  cause. 

CHOREA. 

Although  pathological  changes  in  the  brain  and 
spinal  cord  have  been  found  in  many  cases  of  chorea, 
they  vary  so  much  in  situation  and  character  and  are 
so  frequently  absent,  that  no  definite  conclusion  can  be 
drawn  from  them  as  to  the  cause  of  the  aflfection. 
Hence  it  is  classed  among  the  neuroses.  An  hereditary 
neuropathic  temperament  usually  underlies  the  disease, 
other  members  of  the  family  frequently  suffering  from 
insanity,  epilepsy  or  hysteria.  It  is  much  more  frequent 
in  the  female  sex,  and  during  the  impressionable  age  of 
childhood.  Fright  is  the  most  frequent  exciting  cause 
where  the  predisposition  exists.  Cases  have  been  attri- 
buted to  intestinal  worms,  and  to  irritation  of  a  periph- 
eral nerve. 

Eye-strain  should  be  remembered  as  a  possible 
factor,  although  the  evidence  of  such  an  influence  rests 
upon  a  much  more  slender  basis  than  with  epilepsy. 
Ranney,  of  New  York,  reports  in  the  "  Medical  Record  " 
for  May  12,  1894,  a  series  of  cases  of  chorea  all  of 
which  were  cured  or  much  benefitted  by  graduated  ten- 
otomies. Stevens  attaches  much  importance  to  errors  of 
refraction  as  a  cause  of  chorea,  and  Gould  claims  to 
have  cured  one  case  by  the  use  of  convex  glasses.  This 
view  is  strongly  opposed  by  other  oculists  of   eminence. 


NEURASTHENIA  AND  HYSTERIA.  155 

The  committee  of  the  N.  Y.  Neurological  Society,  who 
were  appointed  some  years  ago  to  investigate  Dr.  Stev- 
ens' claims,  came  to  the  conclusion  that  they  were  not 
supported  by  facts. 

De  Schweinitz,  of  Philadelphia,  analyzed  227 
cases  of  chorea,  in  which  he  found  either  hypermetropia 
or  hypermetropic  astigmatism  to  exist  in  76  per  cent., 
and  myopia  and  mixed  astigmatism  in  a  few  of  the  re- 
mainder. At  first  sight  this  would  seem  to  afford  strong 
corroborative  testimony  in  favor  of  the  relation  of  cause 
and  effect  between  chorea  and  refractive  errors.  When, 
however,  we  recall  the  fact  that  exactly  the  same,  viz.,  76 
per  cent,  of  all  children  in  the  elementary  schools  have 
hypermetropic  refraction,  the  evidence  seems  as  strong 
that  chorea  causes  hypermetropia   as  the  reverse. 

Although  the  facial  muscles  are  affected  in  nearly 
all  cases,  the  ocular  muscles  are  rarely  involved. 

Lifting  of  the  eyebrows,  closure  of  the  lids  and 
rolling  of  the  eyes  increasing  on  excitement  and  ceas- 
ing during  sleep  have  been  observed  in  this  disease. 
Dilatation  and  inequality  of  the  pupils  may  be  present. 
Nystagmus  occurs  rarely,  and  points  to  a  cerebral  lesion 
as  the  cause  both  of  the  nystagmus  and  of  the  chorea. 
Thus  its  presence  would  be  of  diagnostic  importance  as 
indicating  that  the  latter  was  not  a  simple  neurosis. 

NEURASTHENIA   AND    HYSTERIA. 

Eye-strain  is  a  direct  cause  of  neurasthenia  and 
an  indirect  cause  of   hysteria.     The  former  is  not  a  dis- 


156         THE   EYE   AS   AN  AID   IN   GENERAL   DIAGNOSIS. 

tinct  disease,  but  a  condition  of  nervous  exhaustion 
•which  may  be  due  to  a  variety  of  conditions  both  men- 
tal and  physical,  or  it  may  be  a  direct  sequence  of  defi- 
nite diseases  both  functional  and  structural.  It  is  not 
necessary  to  repeat  in  this  connection  what  has  been 
said  in  reference  to  the  large  expenditure  of  nervous 
energy  required  in  physiological  vision,  and  it  needs  no 
additional  argument  to  emphasize  the  depressing  influ- 
ence of  conditions  demanding  unusual  nervous  eflfort 
such  as  necessarily  attends  the  visual  act  when  errors 
of  refraction  or  weakness  of  the  external  or  internal 
eye-muscles  exist.  Here  again  we  recognize  the  "  vic- 
ious circle "  of  cause  and  effect,  and  will  expect  to 
find,  as  we  do,  all  forms  of  asthenopia  developed  and 
intensified  in  neurasthenia.  There  is  easy  fatigue  of  the 
eyes  and  of  the  visual  centres  and  anaesthesia  of  the 
retina ;  accommodation  and  convergence  are  also  weak. 
These  conditions  explain  the  indistinctness  of  near  vis- 
ion and  the  pain  attending  it,  and  the  necessity  for 
convex  glasses  in  those  who  have  not  previously  re- 
quired them,  as  well  as  the  frequent  change  of  glasses 
which  those  already  dependent  upon  them  require.  The 
retinal  and  central  exhaustion  produces  impainnent  of 
distant  vision,  frequent  alterations  of  the  visual  fields 
and  dilated  and  changeable  pupils.  Romberg  called 
attention  to  an  unusual  symptom  which  he  considered 
peculiar  to  neurasthenic  individuals,  viz.,  an  inability 
to  close  the   eyes    completely   when   standing   with    the 


HYSTERIA.  157 

feet  close  together,  because  of  weakness  of  the  accom- 
modation and  spasm  of  the  sympathetic.  Loenwerg 
states  that  this  symptom  occurs  on  standing,  without  re- 
gara  to  the  position  of  the  feet. 

Certain  peculiar  visual  disorders  occur  in  neuras- 
thenia, but  are  more  frequent  in  hysteria,  and,  therefore, 
they  will  not  be  separately  discussed  here.  There  is  an 
intimate  relation  between  neurasthenia  and  hysteria,  for 
the  former  underlies  a  large  proportion  of  functional 
nervous  diseases,  including  hysteria,  and  is  often  the 
direct  cause  of  them. 

HYSTERIA. 

As  with  epilepsy  and  chorea,  we  recognize  in 
hysteria  also  an  hereditary  neurotic  tendency  which  is 
intensified  by  poor  health,  anaemia  and  any  depressing 
influence  such  as  eye-strain,  which  thus  may  be  enum- 
erated among  the  causes  of  hysteria.  Therefore  the  cor- 
rection of  muscular  and  refractive  errors  is  an  import- 
ant factor  in  the  treatment  of  hysterical  affections. 

To  reverse  the  subject,  we  recognize  many  func- 
tional ocular  affections  manifested  in  the  domain  of 
both  the  cerebral  and  the  sympathetic  nerves  as  a  re- 
sult of  hysteria.  A  general  characteristic  of  such  dis- 
orders is  suddenness  of  onset,  erratic  course,  often  a 
sudden  disappearance,  and  the  absence  of  apparent  ade- 
quate cause  of  ophthalmoscopic  changes  or  other  evidence 


158         THE   EYE   AS   AN   AID   IN  GENERAL  DIAGNOSIS. 

of  pathological  basis  for  the  symptoms  exhibited.     Such 
affections  may,  for  convenience,  be  classified  as : 

a.  Muscular  disorders. 

b.  Disorders  of  sensation. 

c.  Disorders  of  secretion. 

d.  Visual  disorders. 

a.  Muscular  disorders. — Under  this  head  may 
be  mentioned  twitching  and  spasmodic  closure  of  the 
lids  and  spasm  of  accommodation.  The  latter  produces 
apparent  near-sightedness,  indicated  by  more  or  less  in- 
distinctness of  distant  vision  and  an  inclination  to  hold 
objects  nearer  the  eye  in  reading,  writing,  etc.  Spasm 
of  accommodation  is  not  at  all  characteristic  of  func- 
tional nervous  troubles,  for  it  occurs  frequently  in  con- 
nection with  errors  of  refraction,  but  hysteria  and  neu- 
rasthenia increase  the  liability  to  it  when  refractive 
errors  exist. 

Paralytic  affections  occasionally  occur,  among 
which  hysterical  ptosis  is  the  most  common  form.  The 
expression  "  hysterical  ptosis "  is  rather  misleading, 
however,  for  most  cases  are  due  rather  to  a  slight  spasm 
of  the  orbicularis  than  to  a  real  weakness  of  the  levator 
palpebrae.  This  is  demonstrated  by  the  circumstance 
that  when  the  patient  is  told  to  look  up  she  bends  her 
head  backward,  and  if  the  head  is  held,  the  spasmodic 
contraction  of  the  lids  is  manifestly  increased.  In  other 
cases   paralysis   of  the  sympathetic   supplying    the   un- 


HYSTERIA.  159 

striped  muscular  fibres  of  Mueller  may  explain  the 
slight  drooping  of  the  lids. 

It  was  positively  asserted  by  Charcot  in  1892 
that  "  nystagmus  is  never  found  in  hysteria,"  and  Gow- 
ers,  in  the  latest  edition  of  his  treatise  on  nervous  dis- 
eases, lays  special  stress  on  the  importance  of  nystag- 
mus as  a  diagnostic  sign,  indicating  the  existence  of 
"more  than  a  functional  disturbance  of  the  brain  or 
cord." 

A  case  reported  by  Dr.  Sabrazes  in  the  "  Semaine 
Medic.,'^  September  26,  1894,  seems  to  prove  that  these 
statements  of  Charcot  and  Gowers  are  not  to  be  ac- 
cepted without  reservation.  The  patient  had  nystagmus 
without  indication  of  any  lesion  of  the  visual  apparatus, 
associated  with  manifest  indications  of  hysteria.  Hyp- 
notic suggestion  caused  the  immediate  disappearance  of 
all  symptoms  of  disease. 

Frequent  variations  in  the  size  of  the  pupil  with- 
out apparent  cause  was  mentioned  as  a  manifestation 
of  neurasthenia,  and  it  is  also  one  of  the  recorded 
symptoms  of  hysteria. 

b.  Disorders  of  sensation  in  and  around  the 
eyes  as  a  manifestation  of  hysteria  are  frequent  and 
varied.  Pain  occurs  either  spontaneously  or  with  efforts 
of  accommodation.  Tenderness  in  the  ciliary  region 
and  anaesthesia  of  the  skin  of  the  lids  and  of  the  con- 
junctiva and  cornea  are  common. 


160  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

c.  Vasomotor  and  other  sympathetic  distur- 
bances in  the  eye  are  evidenced  by  disorders  of  secre- 
tion such  as  epiphora  without  irritation  or  emotion,  and 
chromidrosis,  or  a  coloration  of  the  skin  of  the  lids  in 
consequence  of  an  abnormal  formation  of  pigment  by 
the  sweat  glands. 

d.  Visual  disorders  have  been  frequently  no- 
ticed in  hysteria.  There  may  be  slight  impairment  of 
vision  or  total  blindness.  Hysterical  amblyopia,  as  it  is 
called,  is  of  sudden  onset  and  unaccompanied  with  oph- 
thalmoscopic changes  or  evidences  of  cerebral  lesions. 
It  may  affect  both  eyes,  but  more  frequently  it  is 
monocular.  The  reaction  of  the  pupil  to  light  may  be 
retained  or  lost.  If  retained  it  indicates  a  cortical  af- 
fection, probably  a  vaso-motor  disturbance  of  the  circu- 
lation. Hysterical  amblyopia  is  usually  of  transient 
duration  and  sudden  in  its  disappearance.  It  is  often 
surprisingly  improved  by  lenses  of  various  sorts,  convex, 
concave  or  prismatic.  The  explanation  of  such  im- 
provement must  be  an  increased  innervation  caused  by 
the  use  of  the  lenses. 

Monocular  amblyopia  with  retained  pupillary  re- 
flex is  strongly  suggestive  of  simulation,  and  the  differ- 
ential diagnosis  between  simulation  and  hysteria  is  dif- 
ficult. Apart  from  other  hysterical  manifestations,  the 
test  for  diplopia  by  means  of  the  stereoscope  and  prisms 
will  afford  valuable  aid  if  carefully  conducted.  Binocu- 
lar  vision    is  essential    for  uniting   the  two   pictures    of 


HYSTERIA.  •    161 

the  stereoscope  into  a  harmonious  single  image.  Hence 
if  the  patient  with  alleged  monocular  amblyopia  sees 
clearly  with  the  stereoscope,  the  simulation  of  blindness 
of  one  eye  is  exposed.  A  prism  of  6°  or  more  held 
with  its  apex  upward  before  one  eye  will  produce  a 
double  image  (one  above  the  other)  of  a  candle  or  gas- 
flame  across  the  room  if  both  eyes  are  used  in  seeing. 
The  eflfect  of  prisms  upon  the  visual  lines  can  also  be 
noted  where  it  is  not  desirable  to  trust  the  statements 
of  the  patient.  If  a  prism  of  6°  to  io°  is  placed  before 
one  eye  with  its  base  out,  while  the  patient's  gaze  is 
directed  towards  an  object  a  few  feet  distant,  the  eye  be- 
hind the  prism  will  make  a  movement  inward  (in  the 
direction  of  the  apex  of  the  prism)  to  avoid  the  diplopia 
caused  by  the  prism,  unless  that  eye  is  blind  or  nearly 
so.  The  detection  of  the  fraud  is  more  difficult  when  the 
patient  asserts  that  the  sight  of  one  eye  is  deficient,  but 
not  entirely  lost.  We  must  then  in  conducting  the  test 
endeavor  to  deceive  him  as  to  which  eye  is  being 
tested.  If  he  is  able  to  read  fine  print  with  the  ambly- 
opic eye  while  he  imagines  he  is  using  the  sound  eye, 
the  simulation  is  apparent.  Such  a  test  may  be  con- 
ducted in  the  following  manner  : 

By  the  aid  of  Snellen's  or  Jaeger's  test-types  we 
ascertain  the  smallest  print  he  can  read  with  the  sound 
eye.  Then,  handing  him  a  spectacle  frame  having  a 
plain   glass   before   the   sound  eye    and  a  strong  convex 

glass  before  the  supposed  amblyopic  eye,  we  ask  him  to 
11 


162  THE    EYE    AS    AN    AID    IN    GENERAL    DIAGNOSIS. 

read  again.  Later,  under  pretext  of  having  neglected  to 
note  the  size  of  the  print  previously  read,  or  for  other 
plausible  reason,  we  repeat  the  test,  this  time  reversing 
the  lenses  so  as  to  bring  the  convex  glass  before  the 
sound  eye.  If  he  now  reads  the  same  print  at  the 
former  distance,  the  diagnosis  is  established. 

Monocular  diplopia  is  sometimes  an  hysterical 
manifestation  and  is  usually  caused  by  a  spasm  of  ac- 
commodation, as  is  evidenced  by  the  fact  that  the  di- 
plopia disappears  under  the  use  of  atropin  for  the  re- 
laxation of  accommodation.  Dr.  Lagrange  reported  to 
the  "  Medical  and  Surgical  Society  of  Bordeaux,"  in 
November,  1894,  a  case  of  hysterical  monocular  diplopia 
which  was  unusual,  in  that  it  was  evidently  due  to  a 
cerebral  condition,  and  in  which  the  diplopia  was  cured 
by  hypnotic  suggestion.  In  this  case  the  diplopia  was 
uninfluenced  by  the  use  df  atropin. 

There  is  a  peculiar  form  of  the  visual  field  which 
Charcot  considers  characteristic  of  hysteria,  especially 
when  it  is  unilateral.  Excentric  vision  gives  us  the 
faculty  of  orientation,  as  it  is  called,  which  is  of  exceed- 
ing value.  If,  in  walking,  for  instance,  we  were  uncon- 
scious of  all  objects  save  those  directly  before  us,  we 
would  not  only  lose  much  of  the  pleasure  of  seeing,  but 
would  be  continually  exposed  to  danger,  for  we  would 
not  notice  the  approach  of  objects  on  either  side; 
neither  could  we  appreciate  the  relative  position  and 
direction  of  objects.     This  is  well  illustrated  in  the  case 


HYSTERIA.  163 

of  retinitis  pigmentosa,  where,  although  central  vision 
in  a  limited  area  may  still  be  preserved  to  such  an 
extent  that  the  patient  is  able  to  read  fine  print,  yet 
be  incapable  of   guiding  himself  alone. 

Certain  diseases  produce  characteristic  alterations 
in  the  form  and  outline  of  the  visual  field.  For  in- 
stance, retro-bulbar  neuritis  causes  a  central  scotoma,  or 
a  loss  of  vision  characterized  by  a  black  spot  in  the 
centre  of  the  field.  In  atrophy  of  the  optic  nerve  there 
is  a  concentric  narrowing  advancing  very  irregularly 
from  the  periphery,  often  commencing  from  the  tem- 
poral side.  Sometimes  the  field  is  quite  uniformly  re- 
stricted on  all  sides,  and,  again,  large  gaps  appear  in 
one  direction  while  the  boundaries  may  be  nearly  nor- 
mal in  all  others.  Glaucoma  produces  a  narrowing, 
usually  manifested  first  on  the  nasal  side.  Hysteria 
sometimes  produces  a  concentric  contraction  with  a 
nearly  uniform  outline  in  all  directions.  This  peculiar 
form  of  the  visual  field,  existing  without  ophthalmo- 
scopic findings,  is  very  characteristic  of  hysteria,  and 
hence  is  worthy  of  remembrance  as  affording  a  valuable 
diagnostic  point  in  certain  cases  when  a  suspicion  of 
cerebral  disease  exists.  It  may  be  associated  with  more 
or  less  impairment  of  central  vision,  and  more  or  less 
loss  of  the  color  sense. 

The  following  case  is  cited  by  way  of  illustra- 
tion. 


164  THE  BYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Addie  C,  a  sensitive,  nervous  child,  fourteen  years 
old  consulted  me  in  February,  1896,  complaining  of 
headache,  indistinctness  of  vision,  restless  dreamful  sleep, 
and  a  variety  of  nervous  symptoms  which  were  appar- 
ently associated  with  the  approach  of  puberty.  She  had 
never  menstruated.  Two  years  previously  I  had  ex- 
amined her  and  found  slight  hyperopic  astigmatism  in 
each  eye  with  some  amblyopia  of  the  left.  With  glasses 
prescribed  at  that  time  the  vision  of  the  right  eye  was 
II,  and  that  of  the  left  ^. 

These  glasses  she  had  worn  constantly  and  satis- 
factorily until  shortly  before  consulting  me  in  Febru- 
ary, 1896.  At  that  time  v.o.d.=^  and  v.o.s.=^,  and 
could  not  be  improved  by  glasses.  She  could  not  read 
print  finer  than  Sn.  No.  i.  After  paralyzing  the  ac- 
commodation with  atropin  distant  vision  was  the  same, 
and  all  lenses  were  again  refused.  Ophthalmoscopic  ex- 
amination showed  nothing  abnormal.  The  visual  fields 
were  concentrically  contracted,  with  somewhat  irregular 
outlines. 

Under  treatment  for  her  general  health,  rest  of 
the  eyes  and  outdoor  exercise,  there  was  gradual  im- 
provement both  in  central  vision  and  in  the  outline  of 
the  fields  until  August  5,  when  there  was  a  slightly  in- 
creased contraction  of  the  latter.  This  was  only  tem- 
porary, however,  and,  on  the  second  of  September,  she 
again  accepted  the  lenses  which  corrected  the  slight  as- 
tigmatism   previously    demonstrated,    and    vision   of   the 


/6S  ] 


/8(l' 


I9C 


PLATE   III 


March  7?^  '96 

June    5t»)  '96 

Aug.    5  th  '96 

Sept.    20^*96 


PLATE    IV 


/«f 


JJ90 


19.5 


Ey^ 


r," 


"y  s. 


^■Meyrmvitz,  Optloi^^' " 


March  7'»?  '9& 
June  51'?  *96 
Auy.  5'n  '96 
Sept.   2^^'96 


HYSTERIA.  165 

right  eye  was  again  -^  and  that  of  the  left  -^,  the  vis- 
ual fields  were  practically  normal  as  is  shown  by  the 
appended  charts  (Plates  III  and  IV),  and  she  read  .5 
easily. 

There  are  certain  well-determined  areas  in  which 
the  various  colors  are  perceived.  The  outlines  of  the 
color  fields  differ  from  those  for  form,  and  vary  with 
the   individual  colors  (see  chart  p.   115). 

The  same  incongruity  of  manifestation  which  has 
been  found  in  other  hysterical  affections  is  noticeable 
in  the  outlines  of  the  various  color  fields.  There  may 
be  complete  loss  of  color  perception,  or  the  form  of 
the  fields  may  exhibit  entire  lack  of  uniformity  as  com- 
pared with  the  normal  standard.  With  organic  affec- 
tions we  notice  irregular  contractions  of  the  field  for 
form,  and  regular  contractions  of  the  color  fields,  while 
the  reverse,  viz. :  uniform  concentric  narrowing  of  the 
field  for  form,  and  irregular,  unsymmetrical  contraction 
of  the  color  fields  occurs  in  hysterical  affections. 

Certain  ocular  symptoms  have  been  recorded  in 
connection  with  other  functional  nervous  diseases,  but, 
as  they  possess  no  diagnostic  significance,  they  are  not 
pertinent  to  the  objects  of  this  discussion. 

LOCAL  OCULAR  REFLEX  NEUROSES. 

In  the  introduction  to  this  chapter  functional 
nervous  diseases  were  divided  into  general  or  systemic, 
and  local.  It  remains  to  consider  the  relation  of  oculai 
affections  to  local  neuroses. 


166         THE   EYE   AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

No  argument  is  needed  to  convince  the  ophthal- 
mologist, or  the  general  practitioner,  who  is  conversant 
with  current  medical  literature,  of  the  frequent  depend- 
ence of  headache  of  various  sorts  upon  eye-strain.  The 
cure  of  headache,  often  of  long  standing,  by  the  correc- 
tion of  errors  of  refraction  or  of  heterophoria  is  a  mat- 
ter of  every  day  experience  with  the  specialist  These 
two  sources  of  eye-strain  are  so  often  associated  that  it 
is  difficult  to  determine  their  relative  importance,  some 
writers  attributing  the  greater  influence  to  difficulty  of 
accommodation  and  weakness  of  the  extrinsic  muscles, 
and  others  to  refractive  anomalies.  To  one  or  all  of 
these  conditions  very  many  cases  of  headache  are  due. 
This  fact  should  be  borne  in  mind,  and  a  thorough  ex- 
amination of  the  eyes  should  be  made  in  all  cases  of 
frequent  or  continuous  headache  where  the  cause  for 
the  same  is  not  evident,  or  where  ordinary  treatment  is 
not  satisfactory.  It  has  been  the  experience  of  the 
writer  that  in  these  cases  the  patient  frequently  has 
not  been  conscious  of  any  visual  defect  or  asthenopic 
symptoms,  yet  examination  has  disclosed  a  muscular  or 
refractive  error,  which  has  been  demonstrated  to  be  the 
cause  of  the  headache,  because  correction  of  the  former 
has  been  followed  by  disappearance  of  the  latter.  Such 
cases  emphasize  the  importance  of  ocular  investigation, 
even  in  the  absence  of  eye  symptoms. 

Headaches  from  eye-strain  present  a  variety  of 
forms.     Sub-occipital    pain,  suggestive   of   congestion   of 


LOCAL  OCULAR  REFLEX  NEUROSES.  167 

the  base  of  the  brain,  and  symptoms  of  general  cerebral 
hyperaemia  are  common  ;  also  dull  pain  over  the  eyes 
or  behind  them,  or  extending  from  the  eyes  to  the  ver- 
tex or  occiput,  and  neuralgic  pains  in  and  about  the 
eyes. 

Hemicrania  or  migraine,  popularly  called  "  sick 
headache,"  frequently  follows  over-use  of  the  eyes.  It 
is  probably  an  expression  of  general  nervous  exhaustion 
from  over-exertion  of  weak  organs,  and  the  numerous 
visual  phenomena,  such  as  amblyopia,  scotoma,  hemia- 
nopic  defects,  phosphenes,  muscae  volitanteSy  etc.,  point  to 
an  irritation  of  the  cortical  visual  centre.  These  visual 
symptoms  are  so  pronounced  in  many  cases  as  to  give 
rise  to  the  special  classification  of  "  ophthalmic  mi- 
graine," or  "  scintillating  scotoma."  It  is  characterized 
by  dazzling,  luminous  vibrations  occurring  in  the  right 
or  left  visual  field  of  both  eyes,  with  more  or  less  com- 
plete homonymous  hemianopia  on  the  same  side.  The 
reactions  of  the  pupil  are  preserved,  affording  another 
evidence  of  the  cortical  situation  of  the  disturbance. 
The  attack  may  or  may  not  be  accompanied  with  pain 
and  nausea,  but  the  absence  of  pain  is  the  exception. 
It  admits  of  but  one  explanation,  viz.  :  a  vaso-motor 
disturbance  of  the  visual  area  of  the  cortex  of  the  occi- 
pital lobe  on  the  side  opposite  to  the  affected  visual 
field.  It  may  be  a  reflex  ocular  neurosis,  but  it  fre- 
quently results  from  other  causes,  and  is  sometimes  a 
manifestation    of    hysteria.       Pure    scintilating    scotoma, 


168  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

without  fully-developed  migraine,  is  comparatively  of 
frequent  occurrence  in  brain  workers,  and  is  not  of 
serious  import. 

Visual  symptoms  occur  in  fully  one-half  of  the 
cases  of  migraine,  and  their  existence  is  of  importance 
in  making  a  diflferential  diagnosis  between  the  latter 
afiFection  and  supra  or  infra  orbital  neuralgia.  Photo- 
phobia, lacrymation  and  conjunctivitis  occur  with  both 
disorders.  We  may  have  either  contracted  or  moderately 
dilated  pupils  with  migraine,  showing  either  spasm  or 
paralysis  of  the  sympathetic.  These  phenomena  are  ab- 
sant  in  pure  neuralgia,  and  in  the  latter,  pressure  upon 
the  nerv'e  is  painful. 

A  severe  case  of  migraine  cured  by  correction  of 
compound  myopic  astigmatism  was  reported  by  Noyes. 

Dr.  O.  Landman  in  a  recent  journal  "  attempts 
to  determine  the  character  and  behavior  of  headaches 
dependent  upon  an  uncorrected  error  of  refraction.  Ac- 
cording to  him,  migraine  is  only  rarely  caused  by  error 
of  refraction,  even  when  it  is  accompanied  by  this.  It 
is  especially  uninterrupted  headache  which  is  caused  by 
some  ocular  defect.  It  is  more  frequent  in  women  than 
in  men,  and  may  generally  be  localized.  Uninterrupted 
difEuse  headache  is  usually  caused  by  a  general  distdr- 
bance.  If  the  patient  complains  of  headache  in  the 
eyes,  or  of  pain  extending  from  the  eye-balls  to  the 
head,  or  surrounding  the  eyes  after  work,  or  situated 
behind    the    eye-balls,  or  of  exasperated    attacks  in   the 


LOCAL  OCULAR  REFLEX  NEUROSES.  169 

evening  in  general,  of  painful  symptoms  yielding  to  re- 
pose, it  is  probable  that  the  cause  resides  in  the  eyes. 
The  author  thinks  that  it  is  refraction  and  not  a  lack 
of  equilibrium  of  the  motor  muscles  of  the  eye  which 
produces  headache.  Two  hundred  cases  of  ocular  head- 
ache present  the  following  subdivisions  of  localization : 
eye-brows,  41  per  cent. ;  top  of  head,  20  per  cent.  ;  oc- 
cipital, 12  per  cent. ;  occipital  frontal,  8  per  cent. ; 
temporal,  8  per  cent.  In  a  single  case,  the  headache 
was  general.  The  forehead  and  the  vertex,  and  the  oc- 
ciput and  the  vertex  were  each  thirteen  times  the  seat 
of  pain ;  occipital  headache  was  frequently  accompanied 
with  stiffness  of  the  nape  of  the  neck." 

Ocular  vertigo  may  be  mentioned  in  this  connec- 
tion, although  we  are  discussing  especially  neuroses  re- 
sulting from  functional  ocular  diseases.  It  is  not  of 
frequent  occurrence,  but  sometimes  it  is  met  with  as  a 
reflex  nervous  manifestation  dependent  upon  paralysis 
of  one  or  or  more  of  the  ocular  muscles.  When  the 
effort  is  made  to  move  the  eye  in  the  direction  of  the 
paralyzed  muscle,  diplopia  and  erroneous  projection  of 
the  visual  field  results,  the  proper  relation  of  ob- 
jects is  lost,  and  vertigo  occurs.  The  trouble  is  usually 
of  transient  duration,  for  the  sensorium  soon  learns  to 
correct  the  false  impressions  received,  but  its  recognition 
is  important  to  prevent  errors  in  prognosis,  and  useless 
and  perhaps  injurious  treatment. 


170         THE   EYE  AS   AN   AID   IN  GENERAL   DIAGNOSIS. 

Insomnia  and  even  mental  aberration  have  been 
ascribed  to  eye-strain.  Baker,  of  San  Diego,  Cal.,  re- 
ports in  "  Southern  Cal.  Prac."  for  January,  1893,  a 
case  of  mental  derangement  in  a  woman  46  years  of 
age  which  was  promptly  relieved  by  correction  of 
mixed  astigmatism.  Baker,  of  Utica,  reports  in  "  Amer- 
ican Journal  of  Insanity,"  April,  1893,  several  cases  of 
"  psychalgia "  relieved  by  correcting  errors  of  refrac- 
tion. 

Herren,  of  Jackson,  in  "  Ophthalmic  Record," 
January,  1893,  reports  recurring  attacks  of  sneezing 
cured  by  correcting  ametropia.  !Miles  reports  in  the 
"  Weekly  Medical  Review,"  1884,  107  cases  of  func- 
tional nervous  diseases  in  which  there  were  frequent 
sneezing,  nose-bleeding,  catarrhal  symptoms  and  itching 
and  tickling  sensations,  which  were  either  much  re- 
lieved or  entirely  cured  by  the  wearing  of  suitable 
glasses'. 

Nausea  is  not  infrequently  caused  by  using  the 
eyes  where  there  exists  an  uncorrected  ametropia  or 
muscular  weakness.  Neuschueler  reports  a  cure  of 
toothache  by  prisms.  (Knies).  Pains  in  the  teeth  fre- 
quently accompany  the  ciliary  pains  of  keratitis,  iritis 
and  cyclitis.  Cases  of  ocular  reflexes  to  distant  parts 
might  be  multiplied,  but  sufficient  evidence  has  been 
offered  to  emphasize  the  fact,  the  remembrance  of 
which  may  be  of  service  occasionally  to  the  intelligent 
and  progressive  physician. 


LOCAL  OCULAR  REFLEX  NEUROSES.  171 

Organic  affections  of  the  eye  are  not  without  in- 
fluence as  sources  of  reflex  phenomena,  but  such  influ- 
ence usually  is  readily  recognized  and  does  not  need 
special  discussion.  It  is,  for  the  most  part,  explained 
by  the  depression,  mental  and  physical,  which  is  en- 
tailed by  pain  and  loss  of  sight. 

One  practical  deduction  from  the  preceding  dis- 
cussion is  that  many  functional  nervous  affections  are 
undoubtedly  dependent  to  a  greater  or  less  degree  upon 
eye-strain,  and  are  relieved  or  radically  cured  by  cor- 
rection of  errors  of  refraction  and  of  heterophoria.  Er- 
rors of  not  more  than  .25  D.  frequently  cause  annoy- 
ance in  persons  of  a  sensitive  nervous  temperament, 
and  their  correction  is  followed  by  a  disappearance  of 
the  symptoms.  Apparently  stupid  and  backward  child- 
ren often  appear  so  because  of  defective  vision. 

On  one  occasion  the  writer  witnessed  relief  fol- 
lowing the  prescription  of  as  weak  a  glass  as  .12  D. 
The  fact  that  such  small  errors  are  frequently  endured 
without  detriment,  is  no  reason  for  always  ignoring 
them,  nor  does  it  invalidate  the  teaching  of  clinical  ex- 
perience in  other  cases.  The  same  conclusions  have 
been  reached  in  regard  to  sources  of  nerve  strain  in 
other  organs,  considerable  departure  from  a  normal 
standard  being  often  endured  without  noticeable  effect, 
and,  on  the  other  hand,  apparently  insignificant  disor- 
ders being  attended  with  serious  reflex  manifestations. 


172  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

What  has  been  demonstrated  in  regard  to  errors 
of  refraction  is  also  true  of  muscular  defects.  "  Latent 
exophoria  or  esophoria  of  2°  to  4°  is  often  physiologi- 
cal, and  requires  no  treatment."  (Maddox  on  Ophthalmo- 
logical  use  of  Prisms).  Higher  degrees  frequently 
diminish  after  wearing  corrective  lenses.  When  they 
occasion  annoyance  they  demand  treatment  either  by 
exercise,  tenotomy,  or  by  the  wearing  of  prisms  or  the 
decentration  of  lenses.  Slight  vertical  deviations  more 
frequently  cause  neurotic  symptoms  than  do  lateral  ones 
of  the  same  degree.  I  have  repeatedly  had  gratif)ing 
results  from  the  use  of  a  vertical  prism  of  one-half  a 
degree. 

If  it  could  be  positively  determined  in  a  given 
case  that  nervous  affections  were  caused  or  aggravated 
by  such  ocular  disorders  as  have  been  mentioned,  it 
would  be  of  inestimable  value.  Such  data  for  an  abso- 
lute diagnosis  do  not  always  exist,  when  pronounced 
subjective  symptoms  connected  with  the  use  of  the  eyes 
are  not  manifested.  In  doubtful  cases  rest  of  the  eyes, 
with  or  without  temporary  paralysis  of  accommoda- 
tion or  temporary  use  of  prisms,  will  solve  the  problem 
either  by  affording  relief  to  the  symptoms,  or  by  de- 
monstrating the  existence  of  such  pronounced  errors 
as  unhesitatingly  demand  correction,  or  that  even  slight 
errors  are  not  well  borne.  Relief  may  be  immediate  or 
gradual  following  treatment  of  ocular  disorders,  and 
much    judgment    and    experience    is    required  to   decide 


LOCAL  OCULAR  REFLEX  NEUROSES.         173 

the  question  of  the  influence  of  eye-strain  in  many  ob- 
scure cases.  This  factor  in  the  aetiology  and  perpet- 
uation of  functional  nervous  affections  should  ever  be 
borne  in  mind  by  the  ophthalmologist,  the  neurologist 
and  the  general  practitioner. 

Another  deduction  from  this  discussion  is  that 
examination  of  the  eyes  is  of  great  value  in  the  differ- 
ential diagnosis  between  functional  and  organic  nervous 
diseases. 


CHAPTER  VIII. 

THE    RELATION   OF   AFFECTIONS   OF   REMOTE    ORGANS  TO 
OCULAR   NEUROSES. 

Functional  ocular  disorders  due  to  distant  and  cir- 
cumscribed foci  of  irritation,  either  functional  or  organic, 
will  now  be  considered.  An  inquiry  into  the  mechan- 
ism and  paths  of  reflex  action,  both  physiological  and 
pathological,  will  enable  us  to  understand  the  subject 
more  clearly  and  to  appreciate  its  discussion. 

For  the  production  of  reflex  action  three  factors 
are  necessary :  first,  an  afferent  impulse  starting  from 
the  peripher}',  second,  a  reflex  centre,  and  third,  an 
efferent  impulse  starting  from  this  centre  and  extending 
to  the  part  where  the  reflex  action  is  manifested.  Two 
varieties  of  physiological  reflex  action  are  familiar,  un- 
der the  designation  of  the  skin  reflex  and  the  tendon 
reflex.  Irritation  of  the  skin  of  the  foot,  for  instance, 
produces  flexion,  and  a  sharp  blow  on  the  patella  ten- 
don extension  of  the  leg.  In  these  cases  the  path  is 
through  the  cerebrospinal  ner\'ous  system  to  and  from 
the  reflex  centre  of  the  cord. 

An  afferent  impulse  may  travel  upward  to  the 
brain  producing  a  sensation  which  again  is  reflected  to 
a    distant  part  or  organ.      In  the  feeling  of  faintness  or 

(174) 


RELATION  OF  AFFECTIONS  OP  EEMOTE  ORGANS.    175 

nausea  from  an  unpleasant  sight,  for  instance  the  eflFer- 
ent  influence  is  transmitted  through  the  pneumo-gastric, 
and  in  blushing,  a  vaso-motor  influence  is  directed  to 
the  capillaries  of  the  face.  A  sensation  of  pain  may  be 
felt  in  a  remote  locality  by  reflex  influence  emanating 
from  a  diseased  part,  or  by  simple  suggestion,  as  by  con- 
centrating the  attention  upon  a  given  portion  of  the 
body. 

The  functions  of  organic  life  are  maintained 
through  the  agency  of  the  unstriped  muscular  fibres  in 
the  viscera  and  blood-vessels  under  the  control  of  the 
sympathetic  system.  Respiration,  circulation,  secretion, 
etc.,  are  reflex  acts  which,  as  well  as  the  general  nutri- 
tion of  the  body,  are  regulated  and  dominated  by  the 
reflex  centres  in  the  medulla  and  the  higher  cere- 
bral centres.  While  the  sympathetic  nerves  contain 
motor  fibres  in  large  proportion,  they  also  transmit  af- 
ferent sensory  impressions  from  the  viscera,  and  the  in- 
timate connection  between  the  cerebro-spinal  and  the 
sympathetic  or,  as  Foster  calls  it,  the  splanchnic  systems 
of  nerves,  permits  ready  transmission  of  impressions 
from  one  system  to  the  other.  The  vaso-motor  nerves, 
by  which  the  calibre  of  the  vessels  is  controlled,  and 
the  blood  supply  regulated  according  to  the  physiologi- 
cal requirements  of  nutrition,  secretion  and  general 
functional  activity,  are  controlled  by  the  vaso-motor 
centres  in  the  cord,  and  by  the  higher  centre  in  the 
medulla. 


176  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Thus  we  see  that  reflex  action  may  take  place 
through  the  medium  of  either  the  cerebro-spinal  or  the 
sympathetic  systems,  singly  or  jointly,  and  may  be 
manifested  as  psychic,  sensory,  motor,  vaso-motor  and 
trophic  phenomena.  The  effect  depends  upon  the 
strength  of  the  initial  impression  and  the  condition  of 
excitability  of  the  centre.  There  are  well-defined  chan- 
nels for  the  conduction  of  the  ordinary  physiological  re- 
flexes, but  the  structure  of  the  central  nervous  system 
permits  of  the  transmission  of  the  efferent  impulse 
along  various  paths,  and  we  find  pathological  reflex  ac- 
tion to  be  either  a  diminution  or  increase  of  physiologi- 
cal action,  or  a  perversion  of  the  same.  There  are  re- 
flex centres  situated  all  along  the  spinal  cord  which 
receive  and  transmit  sensory  and  motor  influences 
throughout  the  areas  supplied  by  the  corresponding 
spinal  nerves.  Similarly,  there  are  sympathetic  ganglia 
on  either  side  of  the  spine,  along  its  whole  extent,  an- 
astomosing freely  with  all  the  spinal  nerves.  The 
spinal  reflex  centres  communicate  freely  by  anastomos- 
ing fibres,  and,  as  has  been  mentioned,  are  connected 
with  the  higher  reflex  centre  of  the  medulla,  and  con- 
trolled by  it.  The  latter  probably  is  influenced  by  still 
higher  cerebral  centres,  the  exact  location  of  which  has 
not  been  definitely  determined.  This  is  rendered  prob- 
able by  the  reflex  disturbances  following  psychical  im- 
pressions of  fear,  surprise,  disgust,  pain,  etc.  The  spinal 
sympathetic   ganglia    are    continued    upwards    into    the 


RELATION  OF  AFFECTIONS  OF  REMOTE  ORGANS.    177 

cranial  cavity,  and  through  the  cervical,  carotid,  Gas- 
serian,  ophthalmic,  otic,  and  spheno-palatine  ganglia,  are 
in  communication  with   the  cranial  nerves. 

Thus  we  find  an  unbroken  nervous  chain  extend- 
ing all  over  the  body  to  its  remotest  parts,  with  free 
anastomoses  between  the  different  systems  of  nerves. 
Any  sensitive  surface,  under  pathological  conditions, 
may  give  rise  to  reflex  action  of  the  most  diverse 
kinds,  and  the  location  and  nature  of  such  disturbances 
is  determined  by  the  strength  of  the  initial  impression 
and  by  the  condition  of  the  reflex  centres,  the  direction 
of  the  efferent  impulse  being  along  the  "  lines  of  least 
resistance."  Suppose,  for  instance,  an  impression  is  re- 
ceived from  a  diseased  point  at  a  given  spinal  centre. 
The  latter  has  numerous  communicating  lines  in  the 
direction  of  the  sympathetic  and  also  in  the  direction 
of  other  spinal  centres.  If  the  first  centre  is  in  normal 
condition,  no  efferent  influence  is  excited  to  be  transmit- 
ted along  the  nerves  with  which  it  is  in  special  relation. 
The  sensory  influence  is  continued  along  one  of  the 
many  anastomosing  branches,  and  from  centre  to  centre. 
Sooner  or  later,  an  unusually  excitable  centre  is  reached, 
or  one  having  organs  or  tissues  under  its  control  which 
are  in  a  condition  of  lowered  vitality,  or  are  morbidly 
impressionable.  The  deleterious  influence  is  then  mani- 
fested in  one  of  the  ways  referred  to,  when  under 
strictly  physiological  conditions  it  would  still  be  inop- 
erative. A  lessened  or  exaggerated  vaso-motor  control 
12 


178  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

by  the  central  ganglia  may  be  the  determining  factor, 
and  vaso-motor  paralysis  or  spasm  in  the  part  finally 
reached  will  cause  hyperaemia  or  anaemia,  developing, 
if  unchecked,  into  inflammation  with  exudation  and 
perhaps  a  neoplastic  growth,  or  causing  exaggerated,  di- 
minished or  perverted  function.  Reflex  neuroses  usually 
are  vascular  at  first,  and  due  to  vaso-motor  disturbances 
which  induce,  secondarily,  functional  and  organic 
changes. 

On  the  other  hand,  spasm  or  paralysis  of  volun- 
tary muscular  fibre  may  result  through  transmission  of 
the  impulse  along  a  motor  nerve  of  the  cerebro-spinal 
system,  or  only  a  painful  sensation  may  be  experienced 
in  consequence  of  a  remote  excitation. 

Thus  we  understand  how  peripheral  irritation 
from  almost  any  point  may  reach  the  eye,  and  a  knowl- 
edge of  this  fact  may  sometimes  enable  us  to  unravel  a 
difl&cult  case,  and  to  find  a  remedy  for  a  functional  eye 
trouble  through  treatment  intelligently  directed  to  the 
original  cause  of  the  disorder.  Here  great  care  and  dis- 
crimination is  necessary  to  avoid  confounding  mere  coin- 
cidence with  cause  and  effect.  The  eye  symptoms  and 
the  symptoms  of  the  distant  parts  may  both  result 
directly  from  the  same  cause.  Let  us  first  examine 
some  of  the  physiological  ocular  reflexes,  and  then  inquire 
what  are  some  of  the  functional  disturbances  of  the  eye 
which  are  recognized  as  due  to  reflex  influences,  and 
what  pathological  conditions  have  been  demonstrated 
to  occasion  them. 


RELATION  OP  AFFECTIONS  OF  REMOTE  ORGANS.  179 

PHYSIOI.OGICAI.    OCULAR    REFLEXES. 

The  contraction  of  the  pupil  upon  the  stimulus 
of  the  light  and  its  dilatation  following  irritation  of 
the  skin  are  examples  of  physiological  reflex  action. 
In  the  former  case  the  stimulation  of  the  retina  is  con- 
veyed to  the  habenular  ganglion  or  the  anterior  tuber- 
cula  quadrigemina,  and  thence  an  efferent  motor  influ- 
ence is  sent  along  the  motor  oculi.  In  the  latter  the 
peripheral  sensory  nerves  convey  the  impression  through 
the  spinal  cord  to  the  corpora  quadrigemina,  and  thence 
the  motor  influence  travels  down  the  upper  cervical 
cord  and  along  the  cervical  sympathetic  to  the  carotid, 
the  cavernous  and  the  ophthalmic  ganglia,  and  through 
the  ciliary  nerves  to  the  iris.  Winking  and  lachryma- 
tion  from  irritation  of  the  conjunctiva  or  cornea  are 
also  reflex  acts  for  the  protection  of  the  eye. 

Pathological  reflexes,  or  ocular  neuroses,  are  very 
numerous  and  varied,  and  are  of  similar  nature  to  those 
already  enumerated  in  the  discussion  of  general  func- 
tional nervous  diseases. 

Numerous  organic  diseases  are  sometimes  of  re- 
flex origin,  but  in  the  present  discussion  our  attention 
will  be  confined  to  purely  functional  disturbances.  It 
is  not  desirable  to  consider  these  various  neuroses  in 
detail,  but  a  brief  enumeration  of  the  more  frequent 
manifestations  of  reflex  irritation  may  be  helpful  in  pre- 
venting errors  in  diagnosis. 


180  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Where  neurasthenia  and  hysteria  could  be  ex- 
cluded, the  following  conditions  have  been  recorded 
by  trustworthy  observers,  as  caused  directly  by  reflex 
influences  emanating  from  distant  foci  of  irritation> 
and  cured  by  their  removal  :  pain  of  various  kinds 
in  and  about  the  eye,  photophobia,  lachrymation,  nicti- 
tation, ptosis,  lagophthalnius,  temporary  strabismus,  my- 
osis,  mydriasis,  anaemia  and  hyperaemia  of  the  fundus 
from  vaso-motor  spasm  or  paresis,  muscae  volitantes, 
diplopia,  amblyopia,  scotomata  and  concentric  contraction 
of  the  visual  fields. 

Nasal  and  dental  reflexes  are  the  most  frequent, 
and  when  we  consider  the  intimate  nervous  anastomoses 
between  the  nose  and  teeth  and  the  eye,  we  are  not 
surprised  that  such  is  the  case.  "The  spheno-palatine 
ganglion  sends  branches  to  the  nasal  mucosa,  and  is  in 
direct  communication  with  the  Gasserian  ganglion  at 
the  sensory  root  of  the  trigeminus.  The  otic,  ophthal- 
mic, maxillary  and  superior  and  inferior  dental  ganglia 
are  united  in  common  through  the  sympathetic,  giving 
a  rich  field  of  nervous  network,  in  any  part  of  which, 
transmission  of  any  irritation  suflBcient  to  disturb  its 
normal  physiological  functions  could  produce  neurotic 
phenomena." 

The  intimate  relation  between  the  eye  and  the 
nose  is  shown  by  the  physiological  reflex  actions  of  lach- 
rymation following  irritation  of  the  nose,  and  of  sneez- 
ing   attending   irritation    of   the  retina    by  strong   light. 


RELATION  OF  AFFECTIONS  OP  REMOTE  ORGANS.    181 

Various  nasal  conditions  have  caused  ocular  neuroses  by 
reflex  action.  A  distinction  must  be  made  between 
such  functional  neuroses  and  affections  due  to  extension 
of  inflammation,  or  to  the  absorption  of  septic  material 
by  the  blood  vessels  or  lympathics.  Certain  inflamma- 
tory conditions  of  the  structure  of  the  eye  are  also  at 
times  of  reflex  origin  from  nasal  diseases,  but  the  defini- 
tion of  the  term  neuroses,  as  accepted  in  this  treatise, 
precludes  their  discussion. 

Various  authors  have  reported  ocular  affections, 
such  as  those  enumerated,  associated  with  the  following 
nasal  disorders,  viz.  :  polypi,  hypertrophy  of  the  turbi- 
nateds,  abnormalities  of  the  septum,  and  inflammation  of 
the  maxillary,  sphenoidal  and  ethmoidal  sinuses,  which 
were  cured  by  treatment  of  such  conditions  by  galvano- 
cautery  and  operations  with  the  saw  and  snare. 

The  following  cases  reported  by  Dr.  T.  M.  Stew- 
art, of  Cincinnati,  in  the  "  Eye,  Ear  and  Throat  Jour- 
nal," are  cited  by  way  of   illustration : 

Case  First. — "  Mrs.  B.  applied  for  treatment, 
giving  a  history  of  constant  dull  aching  in  the  left  eye, 
gradually  growing  worse  during  the  past  three  years. 
Glasses  had  been  worn  without  relief.  Aching  in  eye 
made  worse  during  each  attack  of  rhinitis,  which  at- 
tacks were  frequent  and  caused  by  the  least  exposure. 
The  left  inferior  meatus  was  quite  patulous,  but  the 
middle  turbinated  body  was  swollen  to  the  extent  of 
touching    the    septum,  and    proved  to   be  a  genuine  hy- 


182  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

pertrophy.  Reduction  of  the  enlarged  turbinated  was 
followed  by  some  relief,  but  not  of  sufficient  amount  to 
call  the  case  cured.  At  a  later  visit  upon  deep  explor- 
ation with  a  probe,  we  found  an  osseous  spur  on  the 
septum  pressing  against  the  middle  turbinated  body. 
This  growth  was  unsuspected  and  entirely  hidden  until 
after  reduction  of  the  enlarged  middle  turbinated.  The 
growth  was  operated  with  the  trephine,  and  no  return 
of  the  headache  and  eyeache  was  noted  for  a  period  of 
three  months.  Re-examination  showed  a  fibrous  band 
of  union  between  the  cut  surface  on  the  septum  and 
the  middle  turbinated.  This  was  cut  away  and  a  dress- 
ing of  borated  gauze  placed  between  the  opposing  sur- 
faces. After  it  was  removed  and  the  parts  healed,  we 
again  had  the  satisfaction  of  noting  the  disappearance 
of  the  head  pains.  Later  the  case  presented  itself  at 
the  clinic,  with  the  report  that  for  five  months  no 
return  had  been  noted  of  the  head  pains.  Previously 
to  reporting  the  case  here,  inquiry  was  made  by  mail, 
and  now  sixteen  months  have  passed  with  no  return  of 
the  trouble." 

Case  Second. — "  Deep  seated  pain  in  the  eyes 
on  reading  or  sewing  for  even  a  few  moments  in  a  wo- 
man aged  thirty-five  years.  Complains  of  pressure  over 
the  bridge  of  the  nose  and  on  top  of  the  head.  Catch- 
ing cold  would  send  streaks  of  pain  from  the  bridge  of 
the  nose  to  the  seat  of  the  steady  pressure  on  top  of 
the  head.     Condition  had  existed  for  over  two  years. 


KELATION  OF  AFFECTIONS  OF  REMOTE  ORGANS.    183 

"  We  found  comparatively  free  breathing  space, 
but  both  middle  turbinateds  were  enlarged  anteriorly, 
crowding  the  outer  walls  and  the  septum.  Removal  of 
the  enlarged  turbinateds  by  the  forceps  stopped  the  pres- 
sure on  top  of  the  head,  but  some  pain  on  use  of  the 
eyes  continued.  Deep  exploration  revealed  an  osseous 
growth  on  the  septum,  and  an  adhesion  to  it  of  the 
posterior  part  of  the  middle  turbinated.  Removal  of  the 
growth  and  division  of  the  adhesion  cured  the  case,  in 
that  ten  months  have  elapsed  with  no  return  of  the 
symptoms." 

Browne,  in  "  Diseases  of  the  Nose  and  Throat," 
reports  a  case  of  glaucoma  cured  by  removal  of  a  nasal 
polypus  after  iridectomy  had  failed  to  relieve.  Goitre 
and  Basedow's  disease  have  been  cured  by  the  same 
means. 

It  is  also  worthy  of  note,  both  as  confirming  the 
causal  relation  of  nasal  and  ocular  affections,  and  as  a 
warning  to  inexperienced  operators,  that  similar  ocular 
affections  have  followed  operations   on  the  nose. 

A  case  in  point  occurred  recently  in  my  own 
practice.  I  removed  an  enchondroma  from  the  right 
side  of  the  septum.  Vision  in  the  eye  on  the  same  side 
declined  from  {^  to  |^^,  without  ophthalmoscopic  changes 
in  the  interior  of  the  eye,  and  with  no  other  apparent 
cause.  The  impairment  of  vision  lasted  for  two  months 
and  again  became  normal. 


184  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Musehold  cured  a  case  of  exophthalmic  goitre  by 
removal  of  a  hyperplastic  growth  of  the  inferior  turbi- 
nated, and  he  reports  five  similar  cases  from  the 
"Deutsche  Medicinische  Wochenschrijt"  Feb.,  1892.  He 
considers  the  disease  a  vaso-dilator  neurosis.  (Dr.  White, 
of  Richmond,  in  the  discussion  of  nasal  neuroses  in 
Burnett's  "  Treatise  on  Diseases  of  Ear,  Nose  and 
Throat "). 

Trousseau  claims  to  have  cured  two  cases  of 
blepharospasm,  one  of  obstinate  scotoma  scintallans,  one 
of  mydriasis  and  three  obstinate  asthenopias  by  treatment 
of  the  nasal  mucus  membrane,  Ziem  reports  a  case  of 
contraction  of  the  visual  field  cured  by  restoring  the 
outflow  from  the  antrum  of  Highmore. 

There  seems  to  be  some  evidence  that  glaucoma 
is,  at  least  in  some  instances,  of  reflex  origin  through 
the  sympathetic  nerves.  Irritation  of  the  sympathetic 
causes  increased  ocular  tension,  while  its  section  causes 
diminished  tension.  The  same  results  follow  irritation 
or  paralysis  of  the  fifth  nerve  by  communication  with 
the  sympathetic  through  the  ciliary  ganglion.  On  first 
thought  one  would  expect  to  find  minus  tension  fol- 
lowing stimulation  of  the  sympathetic,  and  the  reverse 
when  it  is  paralyzed.  The  explanation  lies  probably  in 
a  stimulation  of  the  vaso-dilator  fibres  which  attends  re- 
flex action.  Noyes  remarks  that  "neuralgia  of  the  fifth 
nerve  is  potential,  and  nervous  strain  is  a  provocation 
of  glaucoma."      Ziem  claims  to   have  secured  temporary 


RELATION  OF  AFFECTIONS  OF  REMOTE  ORGANS.    185 

enlargement  of  the  field  in  chronic  glaucoma  by  gal- 
vano-cautery  of  the  nasal  mucous  membrane,  and  Len- 
nox Browne  reports  a  case  of  glaucoma  rapidly  cured 
by  removal  of  a  nasal  polypus. 

The  relation  of  dental  affections,  especially  caries, 
to  ocular  neuroses  is  substantiated  by  the  record  of 
more  numerous  cures  following  treatment  of  the  teeth 
than  in  the  case  of  nasal  reflexes.  Amblyopia  and 
amaurosis  have  been  reported  several  times  in  such 
connection.  Neuralgic  toothache  is  sometimes  a  pro- 
dromal stage  of  glaucoma.  Sous,  in  the  "  Journal  de 
Medicine  de  Bordeaux,"  Nov,  20,  1893,  reports  the  follow- 
ing case :  "A  young  woman,  twenty-one  years  of  age, 
of  a  lymphatic  constitution,  but  in  perfect  health, 
had  vision  reduced  to  -^  and  amplitude  of  accommoda- 
tion much  reduced.  Both  conditions  returned  to  nor- 
mal after  a  dental  condition  was  cared  for.  He  ex- 
plained the  case  by  reflex  action  of  the  superior  max- 
illary division  of  the  fifth  nerve  upon  the  ophthalmic 
branch  of  Willis." 

Reflexes  from  the  outer  and  middle  ear  to  the 
eye  are  occasionally  noted.  Blepharospasm  is  the  most 
frequent  variety. 

The  influence  of  helminthiasis  and  sexual  disor- 
ders in  both  males  and  females  is  frequent  and  needs 
no  comment.  Androgsk)-,  of  St.  Petersburg,  reports  in 
Zehender's  "  Klinische  Monats  blatter  fur  Augenheilkunde," 
Stuttgart,    Vol.  32,    p.  263,  1894,  two   cases   of   chronic 


186  THE   EYE  AS   AN   AID   IN   GENERAL   DIAGNOSIS. 

spasm  of  the  orbicularis  muscle  produced  by  the  pres- 
ence of  tape-worm  in  the  alimentary  canal.  Functional 
uterine  affections  are  more  influential  in  this  direction 
than  organic. 

The  foregoing  discussion  emphasizes  the  depend- 
ence of  certain  functional  eye  troubles  upon  reflex  ac- 
*tion  emanating  from  distant  sources  of  irritation.  In 
the  absence  of  functional  or  organic  constitutional  dis- 
ease which  would  offer  a  probable  explanation  of  such 
existing  eye  symptoms,  and  when  no  satisfactory  cau.se 
for  them  is  found  in  the  eye  or  its  appendages,  and  yet 
they  do  not  yield  to  appropriate  treatment,  then  a  reflex 
origin  is  to  be  sought  in  the  nose,  the  teeth,  the  ear, 
or  in  the  digestive  and  sexual  systems. 


PART  THIRD. 


OCULAR  AFFECTIONS  OF  TOXIC  ORIGIN. 


(187) 


CHAPTER  IX. 

TOXIC    AMBLYOPIA.      CHRONIC    RETRO-BULBAR    NEURITIS. 

Certain  drugs,  when  administered  internally,  ex- 
ternally or  hypodermically,  are  capable  of  causing  ocu- 
lar symptoms  which  may  or  may  not  be  of  serious  im- 
port, but  which  it  is  important  to  recognize.  They 
advise  the  observant  physician  that  a  remedy  is  not 
well  borne,  or  that  the  patient  possesses  a  peculiar  sus- 
ceptibility to  it.  A  knowledge  of  these  occasional 
occurrences  is  a  check  upon  the  injudicious  and  careless 
employment  of  such  remedies,  or  when  such  drug  effects 
are  simply  annoying  and  not  dangerous,  their  recogni- 
tion enables  the  physician  to  quiet  unnecessary  appre- 
hension on  the  part  of  the  patient  or  friends.  Many 
poisons  produce  characteristic  eye  symptoms  which  are 
an  important  aid  in  the  diagnosis  of  the  substance 
which  has  been  administered  by  accident  or  design, 
and  thus  may  be  not  only  a  guide  to  treatment,  but 
of  prime  importance  in  a  medico-legal  aspect.  Again 
the  existence  of  certain  eye  symptoms  sometimes  affords 
an  explanation  of  obscure  conditions  in  other  parts  of 
the  body  due  to  toxic  influences  hitherto  unsuspected. 
Certain  articles  of  food  and  drink,  if  improperly  pre- 
pared,   or   when   taken    immoderately,    or   where    a    per- 

(189) 


190  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

sonal  idiosyncracy  exists,  cause  a  condition  of  toxaemia 
which  gives  rise  to  ocular  symptoms,  the  explanation 
of  which  is  important,  both  as  regards  diagnosis  and 
treatment.  The  same  may  be  said  of  ptomaine  poison- 
ing. Certain  avocations  require  the  use  of  noxious  sub- 
stances which  affect  the  eye  or  the  vision,  and  their 
recognition  is  also  important.  It  is  not  my  purpose  in 
the  present  discussion  to  enumerate  every  recorded  toxic 
symptom  that  has  been  observed  in  the  department  of 
ophthalmology,  but  only  those  of  diagnostic  importance 
either  as  determining  the  cause  and  nature  of  the  ocu- 
lar manifestations,  or  as  an  aid  in  the  diagnosis  of 
constitutional  disorders.  Only  those  affections  which 
are  directly  of  toxic  origin  will  be  considered.  Those 
due  to  uraemia  or  occurring  in  the  course  of  diabetes, 
although  in  reality  of  a  toxic  nature,  or  those  which 
are  the  indirect  result  of  poisons  which  induce  vascular 
changes,  such  as  occur  in  chronic  alcoholism  or  those 
consecutive  to  cerebral  or  spinal  or  cardiac  lesions  will 
not  be  discussed  here.  The  reader  is  referred  to  other 
portions  of  this  work  for  a  consideration  of  such  affect- 
ions.    The  present  topic  may  be  classified  as  follows : 

I.  Toxic  amblyopia. — By  this  tenn  is  ordinarily 
understood  the  disturbances  of  vision  caused  by  the  in- 
ordinate use  of  tobacco  and  alcohol.  I  shall  also  con- 
sider under  this  head  similar  disturbances  of  vision 
caused  by  various  other  substances. 


toxic  amblyopia.  191 

II.  Ocular  Affections  Following  the  Em- 
ployment OF  Various  Therapeutic  Agents. 

III.  The  Effects  of  Non-Medicinal  Poison- 
ous Substances  and  those  Attending  Certain 
Avocations. 

IV.  Ocular  Affections  due  to  Toxic  Sub- 
stances Contained  in  Certain  Articles  of  Food 
and  Drink:  a.  Fungus  Poisoning;  b.  Ptomaine 
Poisoning. 

V.  Ocular  Conditions  During  and  Follow- 
ing Anaesthesia. 

I.   Toxic  Amblyopia. 

A.     tobacco   and  alcohol  amblyopia. 

Each  of  these  agents  causes  a  disturbance  of 
vision  with  nearly  identical  symptoms  and  they  are, 
therefore,  mentioned  together.  As  will  be  indicated 
later  there  are  slight  differences  in  their  manifestations, 
but  the  essential  phenomena  from  which  the  diagnosis 
of  the  affection  is  made  are  the  same.  Usually  both 
agents  are  factors  in  producing  the  disease,  but  either 
alone  has  occasioned  it.  Long  continued  and  excessive 
indulgence  in  either  alcohol  or  tobacco  is  necessary  for 
its  development.  It  seldom  occurs  in  persons  under 
thirty-five  years  of  age,  and  it  is  usually  older  individ- 
uals with  impaired  nutrition  who  are  thus  affected. 
Much  depends  also  upon  the  quality  of  the  liquor  and 
the    tobacco    used.     There    is    more    fusel    oil    in    poor 


192  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

whiskey,  and  more  nicotine  in  the  inferior  and  cheaper 
grades  of  tobacco,  than  in  the  more  expensive  varieties. 
Hence  we  find  more  cases  of  toxic  amblyopia  among 
the  poorer  classes. 

Berry  in  "  Trans.  Oph.  Soc.  United  Kingdom," 
Vol.  VII,  p.  91,  estimates  the  amount  of  tobacco  which 
causes  amblyopia  as  from  one  ounce  to  half  a  pound  or 
more  weekly.  The  effect  depends  somewhat  upon  the 
manner  of  using  tobacco.  Smoking  when  the  stomach 
is  empty,  and  inhaling  the  smoke  whereby  it  comes  in 
contact  with  a  large  absorbing  mucous  surface,  is  espe- 
cially injurious.  Personal  idiosyncrasy  is  also  a  very 
important  factor  influencing  the  development  of  toxic 
symptoms. 

As  most  habitual  drinkers  also  use  tobacco  it  is 
difficult  in  most  cases  to  determine  the  relative  import- 
ance of  each.  In  France  the  greater  influence  is 
assigned  by  many  writers  to  alcohol,  but  most  authori- 
ties consider  tobacco  as  responsible  for  the  larger  num- 
ber of  cases  of  toxic  amblyopia. 

Among  Orientals,  where  the  use  of  the  weed  is 
almost  universal,  visual  disturbance  as  a  result  is  very 
infrequent.  This  immunity  is  ascribed  to  the  mildness 
of  the  tobacco  and  to  the  way  in  which  it  is  used. 
De  Schweinitz  says  ('•  Toxic  Amblyopias,"  1896)  "  Turks 
while  smoking  cigarettes,  are  particular  that  no  tobacco 
shall  come  in  contact  with  the  buccal  mucous  mem- 
brane, and,  although   they  inhale  the  smoke  vigorously. 


TOXIC    AMBLYOPIA.  193 

they  are  not  poisoned,  because,  according  to  Von  Milli- 
gen,  tobacco  poisoning  (and  hence  amblyopia)  is  possible 
only  when  nicotine  in  solution  is  brought  in  contact 
with  the  mucous  membrane  of  the  mouth  and  swal- 
lowed." 

Smoking  is  more  harmful  than  chewing,  but 
Noyes,  in  his  "  Diseases  of  the  Eye,"  p.  683,  asserts 
that  he  has  observed  the  disease  as  a  result  of  chewing 
alone.  Cases  are  also  on  record  where  it  has  been 
caused  by  the  practice  of  "  dipping "  or  rubbing  snufF 
upon  the   gums. 

In  a  tabulated  report  of  204  cases  of  retro-bulbar 
neuritis  (the  pathological  condition  which  obtains  in 
toxic  amblyopia)  he  found  64  to  be  the  result  of  alco- 
hol, 23  the  result  of  tobacco,  and  45  were  attributed  to 
the  combined  influence  of  the  two,  so  that  more  than 
one-half  of  the  whole  number  resulted  from  one  or  both 
of  these  agents. 

Uhthoff  (see  Graefe's  Archive,  Bd.  XXXII,  et  al.) 
examined  1000  cases  of  alcoholic  excess,  in  which  he 
found  6  per  cent,  of  amblyopia,  and  other  6,5  per  cent, 
exhibiting  the  lesion  of  the  optic  nerve  which  is  char- 
acteristic of  toxic  amblyopia,  but  in  which  the  visual 
symptoms  had  not  developed. 

In    the    "  Quarterly    Journal    of     Inebriety,"    for 

Jan.,  1893,  Dowling,  of  Cincinnati,  publishes  a  report  of 

an  examination  of  150   employees  in  a   tobacco   factory, 

among    whom    45    exhibited    more    or    less    evidence  of 

13 


194  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

tobacco  amblyopia.  He  thinks  the  inhalation  of  tobacco 
dust  is  capable  of  producing  the  disease. 

It  does  not  require  expert  skill  or  long  experi- 
ence to  diagnose  the  affection.  The  ophthalmoscopic 
symptoms  are  absent  or  trivial  until  a  late  stage,  hence 
the  diagnosis  is  made  from  the  subjective  symptoms. 

There  is  an  acute,  non-toxic  form  of  retro-bulbar 
neuritis  resulting  from  severe  exertion,  sudden  chilling 
of  the  body,  suppression  of  menstruation,  rheumatism, 
syphilis  or  lead  poisoning,  or  sometimes  accompanying 
infectious  diseases,  especially  measles,  angina  and  influ- 
enza. In  these  cases  it  is  evident  that  a  condition  of 
toxaemia  underlies  and  causes  the  amblyopia,  but  not  in 
the  sense  of  the  present  discussion.  These  cases  are 
sudden  in  development,  and  are  accompanied  with  more 
or  less  pain  in  and  around  the  eyes.  The  loss  of  vis- 
ion may  be  complete,  while  this  has  very  rarely  been 
recorded  in  the  case  of  tobacco  or  alcohol  amblyopia. 
The  acute  form  is  more  often  unilateral,  while  the 
chronic  toxic  form  is  very  rarely  limited  to  one  eye. 

Dr.  d'Oench,  of  New  York,  reported  a  case  of 
toxic  amblyopia  due  apparently  to  the  abuse  of  alcohol 
and  tobacco,  in  which  within  the  short  space  of  twelve 
hours,  vision  was  reduced  from  the  normal  standard  to 
the  ability  only  to  count  fingers  at  two  feet  distance 
from  the  eye.  (See  "N.  Y.  Med.  Record,"  July  14, 
1894). 


TOXIC    AMBLYOPIA.  195 

The  patient  usually  exhibits  a  gradual  failure  of 
central  vision  constituting  a  central  scotoma,  a  hiatus 
or  black  spot  in  the  centre  of  the  visual  field,  while  the 
peripheral  vision  remains  unimpaired.  At  first  the  vis- 
ion for  color  fails,  red  and  green  are  not  as  bright  as 
formerly,  and  later  are  not  recognized  at  all.  Soon  the 
perception  of  blue  and  yellow  fails,  and  later,  not  even 
the  form  of  objects  is  recognized,  and  a  perfect  blank 
in  the  centre  of  the  visual  field  is  left.  The  patient 
sees  nothing  directly  in  the  line  of  vision,  although  ob- 
jects at  one  side  are  seen  with  the  usual  distinctness. 
He,  therefore,  cannot  see  to  read  or  write,  or  if  the 
scotoma  is  not  too  large,  the  middle  of  a  sentence  or, 
perhaps,  of  a  word  is  lost,  while  the  two  ends  of  the 
line  are  seen  imperfectly.  It  is  very  rare  for  periph- 
eral vision  to  be  lost,  so  that  complete  blindness  is  not 
to  be  feared.  Usually  both  eyes  are  equally  affected. 
Patients  often  complain  of  an  annoying  sense  of  daz- 
zling when  in  a  bright  light,  and  this  may  be  the  first 
symptom  for  which  the  individual  consults  the  physi- 
cian. Owing  to  this  circumstance,  the  patient  declares 
that  he  sees  better  in  a  dim  light,  and  in  some  in- 
stances this  is  true  to  a  limited  extent,  although,  as  a 
rule,  the  improvement  is  more  imaginary  than  real. 

Pathology. — The  pathological  basis  of  this  con- 
dition is  an  atrophy  of  the  bundle  of  fibres  in  the  optic 
nerve  which  supplies  the  macula  lutea  and  its  imme- 
diate vicinity.     This  atrophy  is  the  result  of  a  slow  and 


196  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

slight  interstitial  neuritis,  but  the  acute  variety  of  re- 
tro-bulbar  neuritis  is  designated  as  inflammatory,  in  dis- 
tinction from  the  chronic  toxic  form  in  which  there  is 
no  pain  or  other  manifest  signs  of  inflammation. 

The  situation  of  this  atrophy  is  at  first  in  the 
portion  of  the  nerve  lying  in  the  optic  canal,  that  is, 
behind  the  eyeball  and  in  front  of  the  chiasm,  as  its 
name  implies.  As  the  disease  progresses,  the  atrophic 
process  extends  downward  until  it  becomes  evident  at 
the  optic  disc,  by  ophthalmoscopic  examination,  at  its 
lower  temporal  side,  for  it  is  at  this  point  that  the 
bundle  of  fibres  designated  enters  the  eyeball.  I^he 
selection  of  this  special  bundle  of  fibres  by  these  poi- 
sonous agents  is  an  interesting  and  hitherto  unexplained 
fact.  It  is  not  invariable,  for  cases  have  been  reported 
where  the  peripheral  fibres  were  aflfected,  leaving  the 
macular  bundles  intact,  in  which  case,  of  course,  the 
peripheral  vision  would  be  lost  and  central  vision  be 
retained.  This,  however,  is  of  very  exceptional  occur- 
rence, and  is  not  pathognomonic  of  tobacco  or  alcohol 
amblyopia.  There  is  no  noticeable  change  in  the  ap- 
pearance of  the  vessels  of  the  disc  or  retina. 

DIFFERENTIAL  DIAGNOSIS   BETWEEN   TOBACCO   AND 
ALCOHOL   AMBLYOPIA. 

In  alcohol  poisoning  the  scotoma  is  central  and 
always  includes  the  point  of  fixation,  but  with  tobacco 
the  scotoma  is  very  near  but  not  at  the  point  of  fixa- 
tion.     This   is    probably   not    invariably  the   case.      In 


TOXIC    AMBLYOPIA. 


197 


tobacco  amblyopia  the  scotoma  is  usually  of  an  oval 
shape,  with  the  long  horizontal  diameter  extending  be- 
tween the  point  of  fixation  and  the  blind  spot. 

The  following  charts  of  tobacco  and  alcohol  sco- 
tomas are  taken  from  de  Schweinitz's  "  Toxic  Ambly- 
opia." 


Tobacco    Amblyopia ;    absolute    central    scotomas ;   peripheral 
boundaries  of  field   normal  in  extent. 


Typical  oval  scotomas  from  a  case  of  tobacco  amblyopia. 
The  patient,  aged  sixty,  had  smoked  five  pipes  of  tobacco  daily  and 
an  occasional  cigar  since  he  was  nineteen  ;  a  moderate  beer  drinker. 


198  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

With  tobacco  the  amblyopia  is  oftener  unilateral 
or  differing  in  degree  in  the  two  eyes.  With  alcohol 
the  pupil  is  dilated  and  the  accommodation  weak,  while 
with  tobacco  we  find  a  contracted  pupil  and  spasm  of 
accommodation.  Paresis  of  accommodation  may  be  one 
of  the  first  disorders  of  vision  of  chronic  inebriety,  and 
should  serve  as  a  warning  not  to  be   disregarded. 

The  alcoholic  form  of  the  disease  develops  rather 
more  rapidly  than  that  due  to  tobacco,  and  the  latter  is 
less  amenable  to  treatment. 

In  this  connection  certain  other  ocular  phenom- 
ena accompanying  intoxication  with  alcohol  are  worthy 
of  mention,  viz. : 

Marked  concentric  narrowing  of  the  visual  field 
and  diplopia. 

Sudden  blindness  with  merely  quantitative  per- 
ception of  light,  associated  with  dilated  and  irresponsive 
pupils,  and  with  absence  of  any  abnormal  conditions  of 
the  fundus  as  seen  with  the  ophthalmoscope,  has  been 
observed  in  acute  alcoholism. 

The  differential  diagnosis  between  true  tabes 
and  the  simulation  of  that  disease  resulting  from  chronic 
alcoholism  is  aided  by  remembering  that  myosis  is  ab- 
sent in  the  latter  condition.  Other  symptoms  of  the 
real  affection  are  also  absent,  but  it  is  not  the  province 
of  this  treatise  to  discuss  them. 


TOXIC    AMBLYOPIA.  199 

B.    RETRO-BULBAR   NEURITIS   DUE   TO   OTHER   POISONS. 

Toxic  amblyopia  with  central  scotoma  has  also 
been  caused  by  the  following  substances,  viz, : 

Stramonium. — Fuchs  reports  a  case  caused  by 
smoking  stramonium  leaves  for  the  relief  of  asthma.  See 
Fuchs'  "  Text-book  of  Ophthalmology,"  p.  441. 

Bisulphide  of  Carbon,  Sulphur  Chloride, 
Lead,  and  perhaps  Chloral. — Juler  asserts  that  ex- 
cessive TEA  drinkers  are  predisposed  to  this  disease  and 
opium,  it  is  alleged,  has  also  caused  it. 

Arsenic  has  produced  a  form  of  retro-bulbar 
neuritis,  and  so  has  cannabis  indica. 

Hirschberg  reported  a  typical  case  of  toxic  am- 
blyopia with  central  scotoma  and  without  ophthalmo- 
scopic changes  occurring  in  a  girl  of  sixteen,  upon  whom 
iodoform  was  being  used  locally  after  a  resection  of 
the  hip.  A  similar  result  was  observed  by  Hutchinson 
during  the  internal  administration  of  the  drug  in  com- 
bination with  Creosote.  This  fact  should  be  borne  in 
mind,  that  the  first  indication  of  such  poisonous  influ- 
ence may  be  recognized,  in  view  of  the  extensive  use 
of  this  drug  as  a  topical  application. 


CHAPTER  X. 

OCULAR    AFFECTIONS    CAUSED   BY   VARIOUS  THERAPEUTIC 

AGENTS. 

Various  drugs  in  addition  to  those  already  men- 
tioned sometimes  produce  toxic  symptoms,  such  as  im- 
paired vision,  pupillary  phenomena,  disturbances  of  ac- 
commodation and  of  motility,  and  even  organic  lesions 
of  various  structures  of  the  eye  which  it  is  desirable  to 
consider. 

A.     DISORDERS   OF   VISION. 

Quinine  Amaurosis. — Quinine  produces  a  dis- 
turbance of  vision  exactly  the  reverse  of  that  which 
has  been  described  as  due  to  the  influence  of  tobacco 
and  alcohol,  viz. :  a  condition  sometimes  designated  as 
telescopic  vision.  The  periphery  of  the  visual  field  is 
lost,  and  vision  is  restricted  to  a  ver>'  narrow  area  in 
the  centre,  frequently  of  an  elliptical  shape  with  the 
long  axis  horizontal.  The  following  charts  illustrate 
the  condition.  They  are  taken  from  de  Schweinitz. 
The  shaded  areas  represent  the  limits  of  the  field. 

Usually  there  is,  at  first,  more  or  less  loss  of 
central  vision  which  sometimes  amounts  to  complete 
blindness.     Therefore  we  speak  of  quinine  amaurosis  in- 

(200) 


OCULAR  AFFECTIONS  CAUSED  BY  DRUGS. 


201 


stead  of  amblyopia,  by  which  latter  expression  we  desig- 
nate the  slighter  impairment  of  sight  which  results 
from  the  influence  of  tobacco  and  alcohol. 

The  amaurosis  lasts  from  a  few  hours  to  several 
weeks.  Many  cases  completely  recover.  In  many  others 
the  peripheral  vision  remains  permanently  impaired,  and 
in  a  few  there  is  but  slight  improvement  of  central 
vision.     This  was   true  in  a  case    that   came    under  my 


i^. 


R.E. 


Visual  fields  in  a  case  of  quinine  amaurosis  three  months  after 
recovery  from  complete  blindness. 

own  observation.  In  addition  to  the  visual  symptoms 
mentioned  there  may  be  hallucinations  of  sight,  mydri- 
asis, impaired  accommodation,  anaesthesia  of  the  cornea, 
nystagmus,  divergent  strabismus  and  slight  exophthal- 
mus. 

The  amblyopia  develops  suddenly.  Noyes  says 
that  it  is  always  the  result  of  large  doses,  and  usually 
of  repeated    large    doses,  and    that  no   cases    have    been 


202  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

recorded  where  it  resulted  from  small  or  even  moderate 
doses.  He  does  not  define  what  he  means  by  small  or 
moderate  but  mentions  one  case  that  developed  after 
taking  four  hundred  and  eighty  grains  in  the  course 
of  twenty-four  hours. 

The  inaccuracy  of  his  assertion  is  demonstrated 
by  a  case  reported  by  Pischl,  of  San  Francisco,  in  the 
"Medical  News"  for  July  20,  1893.  Only  thirty  grains 
were  taken  during  twenty-four  hours.  While  central 
vision  was  but  slightly  affected,  the  fields  were  con- 
tracted to  5°.  It  will  be  remembered  that  the  natural 
limits  are  from  45°to  90°,  varying  in  different  direc- 
tions, being  limited  upward  and  toward  the  median  side 
by  the  projection  of  the  brows  and  the  bridge  of  the 
nose  (see  chart  of  normal  field,  p.  115).  After  five 
weeks'  treatment  there  was  only  partial  recovery. 

Cases  of  amblyopia  have  also  been  reported  fol- 
lowing the  exhibition  of  fifteen,  twelve,  and  even  a 
fewer  number  of  grains  in  twenty-four  hours.  The 
effect  depends  largely  upon  individual  idiosyncrasy,  and 
persons  of  a  neurotic  temperament  are  more  susceptible 
to  its  toxic  influence.  Such  cases  as  those  to  which  al- 
lusion has  been  made  ought  certainly  to  teach  caution 
in  the  use  of  the  remedy,  and  it  is  important  to  remem- 
ber that  a  person  who  has  once  suffered  from  quinine 
amaurosis  is  afterward  much  more  susceptible  to  the 
toxic  influence  of  the  drug.  Other  alkaloids  of  cin- 
chona, especially  cinchonine  and  cinchonidine,  occasion- 


OCULAR  AFFECTIONS  CAUSED  BY  DRUGS.  203 

ally  have    the   same  effect    upon   vision,  and  it   has   fol- 
lowed the  use  of   the  tincture. 

Claiborne,  of  New  York,  in  the  "  Medical  Rec- 
ord"  for  August  14,  1894,  formulates  his  conclusions  in 
regard  to  quinine   amaurosis  as  follows  : 

"  I.  Quinine    in    toxic    doses     may    produce    blind- 
ness. 

2.  The  duration  of  the  amaurosis  varies  greatly. 

3.  The  toxic  dose  is  distinctly  indeterminate. 

4.  The  field  of  vision  remains  contracted. 

5.  Central  vision  usually  returns  to  normal. 

6.  There  is  color  blindness  at  first,  color  percep- 
tion being  ultimately  restored  in  the  central  field. 

7.  The  ophthalmological  picture  is  that  of  white 
atrophy. 

8.  Experiments  upon  dogs  show  that  there  is 
atrophy  of  the  entire  optic  tract. 

9.  The  same  experiments  show  that  the  cells  of 
the  cuneus  are  probably  not  affected. 

10.  Treatment  is  of  no  avail." 

Pathology. — The  ophthalmoscope  shows  a  con- 
dition of  ischaemia  of  the  retina,  which  affords  an  ex- 
planation of  the  visual  symptoms  by  the  occurrence  of 
sudden  arterial  spasm.  Both  veins  and  arteries  are  very 
much  contracted.  There  are,  as  a  rule,  no  ophthalmo- 
scopic evidences  of  inflammation  or  exudation.  Knies 
says  that  a  slight  exudation  may  occur  in  the  macula 
lutea    producing   a    cherry-red  spot,  very  similar   to   the 


204  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

appearance  found  in  embolism  of  the  central  retinal 
artery.  The  optic  discs  appear  paler,  but  their  outlines 
are  sharply  defined. 

De  Schweinitz  in  the  "  Transactions  of  the  Amer- 
ican Ophthalmological  Society,"  for  1891,  p.  23,  says  : 
"  The  original  effect  is  upon  the  vaso-motor  centres,  pro- 
ducing constriction  of  the  vessels ;  finally  changes  in 
the  vessels  themselves  are  set  up,  owing  perhaps  to 
endo-vasculitis.  Thrombosis  may  occur,  and  the  result 
of  all  these  is  an  extensive  atrophy  of  the  visual  tract." 

The  amblyopia  from  quinine  is  usually  associated 
with  sudden  deafness,  but  curiously  enough,  the  latter 
effect  has  usually  been  attributed  to  hyperaemia  instead 
of  anaemia.  In  this  connection  the  remarks  of  the  edi- 
tor of  the  translation  of  Gruber's  work  on  diseases  of 
the  ear  in  the  second  American  edition  are  worthy  of 
mention.     He  says : 

"  Brunner  calls  attention  to  the  contradiction  ex- 
isting between  the  statements  of  aural  and  ophthalmic 
surgeons  concerning  the  effects  of  quinine.  According 
to  Kirchner  and  Roosa,  large  doses  produce  hyperaemia 
and  extravasation  of  blood ;  while  ophthalmologists  state 
that  it  produces  marked  anaemia  of  all  the  retinal  ves- 
sels. It  must,  however,  be  mentioned  that  in  the  expe- 
riments made  by  Gruber  under  Weber  Liel's  supervision, 
the  temperature  in  the  external  auditory  canal  dimin- 
ished after  its  employment,  and  hyperaemia  of  the  canal 
or  of   the  vessels  of   the   malleus    was    never   observed. 


OCULAR  AFFECTIONS  CAUSED  BY  DRUGS.  205 

Similar  results  were  obtained  with  salicylate  of  soda. 
The  mitigation  of  auditory  vertigo  following  its  admin- 
istration would  in  this  way  be  explained  by  ischaemia 
of  the  labyrinthine  vessels." 

SalicyIvATE  of  soda  is  said  to  produce  visual 
symptoms  similar  to  those  which  have  been  mentioned 
as  a  result  of  quinine.  Complete  blindness  has  been 
observed  after  taking  eight  grammes  within  a  space  of 
ten  hours.  It  was  associated  with  marked  mydriasis  and 
with  normal  ophthalmoscopic  appearances.  The  retinal 
veins  were  well  filled.  After  ten  hours  the  patient 
could  count  fingers,  and  vision  was  completely  restored 
in  twenty-four  hours.  (E.  Gatti  in  "  Gaz.  degli  Ospital,^^ 
1880-1,  p.  4). 

Caffein. — Hutchinson  (in  the  "  Centralblatt  fiir 
Augenheilkunde,"  Aug.,  1887,  p.  240)  claims  to  have  seen 
amblyopia  closely  resembling  quinine  amblyopia  result- 
ing from  caffein. 

Ergotine  also  produces  ischaemia  of  the  retina 
with  consequent  impairment  of  vision,  by  reason  of  its 
well-known  effect  upon  the  blood  vessels.  The  possibil- 
ity of  such  a  result  should  be  remembered  when  pre- 
scribing this  drug  for  the  cure  of  uterine  neyomata, 
etc.,  especially  when  a  disposition  to  such  a  condition 
already  exists. 

Among  other  drugs  which  produce  more  or  less 
impairment  of  vision  may  be  mentioned    the  following : 


$06  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

OsMic  Acid  causes  great  and  sudden  but  tempo- 
rary amblyopia,  with  loss  of  the  faculty  of  accommoda- 
tion, and  with  no  ophthalmoscopic  changes  in  the  retina 
or  optic  nerve. 

Antipyrin. — Blindness  lasting  one  minute  was 
reported  after  a  dose  of  15  grains.  De  Schweinitz  re- 
ports the  following  visual  disturbances  noted  by  himself 
after  taking  large  doses  of  the  drug,  viz. :  "  undulations 
in  the  atmosphere,  something  like  those  caused  by  the 
ascent  of  heated  air,  followed  by  an  apparent  shower  of 
sparkling  points  of  light ;  phenomena,  in  other  words, 
which  are  the  frequent  prodromes  of  migraine." 

Bromide  of  Potash  has  produced  sudden  loss 
of  sight  with  pallor  of  the  optic  disc  and  narrow  ves- 
sels. 

Cannabis  Indica,  or  hashish,  frequently  causes 
toxic  amblyopia  with  symptoms  resembling  those  occa- 
sioned by  tobacco  and  alcohol.  Unlike  those  substances, 
its  effects  are  often  unilateral,  and  there  may  be  simply 
a  scotoma  without  color  disturbance.  The  visual  symp- 
toms may  be  associated  with  mydriasis  or  myosis,  and 
disturbance  of  the  accommodation. 

Carbolic  Acid  produced  complete  blindness  last- 
ing two  days  in  a  man,  after  washing  out  the  pleural 
sac  with  100  grammes  of  a  3  per  cent,  solution  (see 
*' Berlin-Klin.  M'ochenschr.;'  1882,  XIX,  p.  748).  It 
causes  also  sluggish  pupils  which  may  be  either  dilated 
or  contracted,  and  without  ophthalmoscopic  changes. 


OCULAR  AFFECTIONS  CAUSED  BY  DRUGS.       207 

Cocaine  lias  produced  amblyopia.  Glaucoma  has 
resulted  from  its  protracted  application  to  the  nasal 
mucous  membrane.  Hence  it  should  be  remembered 
that  such  use  of  the  drug  is  not  entirely  unattended 
with  danger. 

Creolin  is  said  to  occasion  sometimes  more  or 
less  impairment  of  vision. 

Chloral  hydrate  has  caused  temporary  amau- 
rosis. Other  visual  disturbances  similar  to  those  ob- 
served in  hysteria,  dependent  presumably  upon  paresis 
of  the  accommodation,  are  attributed  to  its  influence. 

Digitalis  produces  sometimes  more  or  less  cloud- 
iness of  vision,  due  principally  to  the  mydriasis  which 
it  occasions.  This  knowledge  may  enable  one  to  differ- 
entiate the  drug  influence  from  a  direct  sequence  of  a 
cardiac  lesion. 

Eserine.  Complete  blindness,  of  short  duration, 
has  been  observed  after  its  instillation  into  the  conjunc- 
tival sac. 

Felix  Mas.  When  administering  this  drug  as 
a  taenicide,  it  should  be  borne  in  mind  that  several 
cases  of  blindness  have  been  attributed  to  it.  It 
produces  complete  loss  of  vision  of  both  eyes,  coming 
on  within  twenty-four  hours,  or  after  several  days.  At 
first  there  are  no  ophthalmoscopic  changes,  but  subse- 
quently atrophy  of  the  optic  nerves  develops.  This  cir- 
cumstance demonstrates  that  the  visual  disturbance  is 
not  a  result   of    an    influence    exerted    upon    the    visual 


208  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

centres,  but  an  affection  of  the  optic  nerve  stem,  a  form 
of  retro-bulbar  neuritis.  There  are  no  characteristic 
symptoms  which  admit  of  a  diagnosis  of  the  cause  of 
blindness,  without  the  previous  history  and  attendant 
symptoms. 

Morphine.  Complete  blindness  of  both  eyes 
'was  observed  in  a  patient  who  had  taken  two  grammes 
of  morphine  subcutaneously  within  five  days.  The 
papillae  were  cloudy  and  the  arteries  narrow. 

Resorcin  causes  disturbance  of  vision  in  poison- 
ous doses. 

Visual  hallucinations  result  from  the  influ- 
ence of  Belladonna  and  Atropin,  especially  in  the 
dark.  They  are  also  very  prominent  in  the  intoxica- 
tion from  Cannabis  Indica.  Cocaine,  Aesculus,  San- 
tonins and  Stramonium  also  occasion  them.  With 
Aesculus  the  visions  are  distressing,  and  with  Stra- 
monium they  frequently  take  the  shape  of  bugs,  snakes, 
etc.,  resembling  the  hallucinations  of  mania  a  potu. 

Colored  vision  has  been  noticed  after  various 
remedies,  especially  the  following : 

Violet  vision  is  sometimes  caused  by  Canna- 
bis Indica. 

Yellow  vision  is  characteristic  of  Santonine. 
This  results  within  ten  or  fifteen  minutes  after  the  ad- 
ministration of  the  drug,  and  it  may  be  associated  with 
mydriasis  and  inequality  of  the  pupils.  The  yellow 
vision    is    preceded    transiently   by    violet    vision.      All 


OCULAR  AFFECTIONS  CAUSED  BY  DRUGS.  209 

shadows  appear  in  the  complementary  color,  which  fact 
demonstrates  that  the  peculiar  visual  disturbance  is 
caused  by  a  peripheral  irritation,  and  that  the  central 
visual  sense  is  intact. 

Yellow  vision  also  results  from  Chromic  Acid, 
Digitalis,  Nitrite  of  Amyl  and  Picric  Acid.  With 
the  last  named  drug  this  phenomenon  has  been  noticed 
after  a  small  dose  taken  internally,  too  small  to  produce 
coloration  of  the  media,  and  lasting  an  hour.  This  cir- 
cumstance would  indicate  that  the  xanthopsia  was 
caused  by  an  action  upon  the  visual  centre.  It  was  not 
followed  by  blue  or  violet  vision. 

Iodoform  occasionally  causes  red  or  blue  vis- 
ion, and  colored  vision  has  been  caused  by  Cocaine. 

Color  blindness,  of  a  greater  or  less  degree, 
may  be  caused  by  Quinine  and  those  other  drugs  which 
have  been  mentioned  as  producing  visual  disorders  simi- 
lar to  quinine  amblyopia,  viz.  :  Salicylate  of  Soda, 
Ergot  and  Caffein. 

Phosphorus.  Sparks  and  flashes  of  light  re- 
sult characteristically  from  this  drug,  and  from  Bella- 
donna and  Santonine. 

Micropsia  and  Diplopia  have  also  resulted  from 
the  use  of  Cocaine. 

Hemianopsia  has  been  recorded  as  a  symptom 
following  the  inhalation  of  dilute  Hydrocyanic  Acid, 
and  after  poisoning  with   Carbonic  Oxide.     In  the  lat- 

14 


210         THE   EYE   AS   AN   AID   IN  GENERAL   DIAGNOSIS. 

ter  case  the  loss  of  vision  was  in  the   lower  part  of  the 
visual  fields. 

B.   PUPILLARY  PHENOMENA,   DISTURBANCES  OF  ACCOMMO- 
DATION AND  OTHER   OCULAR   SYMPTOMS  CAUSED 
BY  THERAPEUTIC  AGENTS. 

Mydriasis  is  caused  by  Belladonna  and  its  al- 
kaloid Atropin,  by  Daturine,  Duboisine,  Ergotine, 
Homatropine,  Cocaine,  Aconite,  Digitalis,  Hydro- 
cyanic Acid  and  Cyanide  of  Potash,  Hyoscyamus 
and  its  alkaloids  Hyoscyamine  and  Hyoscine,  by 
Stramonium,  Gelsemium  and  Conium.  Calabar  bean 
in  poisonous  doses  sometimes  causes  mydriasis,  although 
marked  myosis  is  its  usual  effect.  This  circumstance 
might  possibly  prevent  a  mistake  in  diagnosis.  Qui- 
nine produces  mydriasis  preceded  by  transient  myosis. 
Aesculus  Hippocastinum,  much  used  in  the  form  of  a 
cerate  as  an  application  to  hemorrhoids,  produces  great 
dilatation  of  the  pupils  in  connection  with  the  distress- 
ing visions  already  alluded  to.  This  may  aid  in  the 
diagnosis  of  poisoning  from  eating  horse-chestnuts, 
which  sometimes  occurs  in  children.  Although  myosis 
is  considered  pathognomonic  of  Opium  or  Morphine 
narcosis,  the  opposite  effect,  viz.  :  mydriasis,  is  observed 
quite  frequently  in  those  habituated  to  its  use.  It 
should  be  mentioned,  however,  that  myosis  is  never  ab- 
sent in  acute  opium  poisoning,  and  rarely  in  the  chronic 
form. 


1^  OCULAR  AFFECTIONS  CAUSED  BY  DRUGS.  211 

Myosis  results  as  a  prominent  symptom  from  the 
internal  administration  of  the  following  drugs,  viz.  : 
Chloral  (perhaps  preceded  by  transient  mydriasis); 
Calabar  bean  and  its  alkaloid  Eserine,  Pilocarpine, 
Jaborandi,  Morphine  and  Opium  in  its  various  forms 
and  Salicylate  of  Soda.  Quinine  produces  a  tran- 
sient myosis  which  is  soon  followed  by  mydriasis. 

Spasm  of  accommodation  is  usually  associated 
with  contraction  of  the  pupil,  and  paresis  of  accommoda- 
tion with  dilatation,  hence  it  is  unnecessary  to  repeat 
the  drugs  which  cause  these  conditions.  It  is  worthy 
of  remark  in  this  connection  that  in  chronic  morphine 
habitues  the  paradoxical  condition  of  spasm  of  accommo- 
dation associated  with  mydriasis  sometimes  occurs. 

Among  other  ocular  conditions  following  the  em- 
ployment of  various  therapeutic  substances  may  be  men- 
tioned the  following : 

Ptosis  lasting  two  weeks  has  been  produced  by 
Sulfonal,  which  has  become  a  favorite  remedy  for  in- 
somnia. A  knowledge  of  this  fact  may  prove  valuable. 
Partial  ptosis  has  followed  the  use  of  Iodoform. 

Twitching  of  the  Lids  is  caused  by  Calabar 
BEAN,  Eserine  and  Jaborandi. 

Swelling  of  the  Lids  occasionally  occurs  as  an 
effect  of  Chloral. 

Conjunctivitis  sometimes  follows  the  use  of 
Atropin  and  Bromide  of  Potash.  Pustules  may  ap- 
pear on  the  conjunctiva  during  the  employment  of    the 


212  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

latter  drug,  even  when  there  are  none  upon  the  skin. 
Conjunctivitis  with  irritation  of  the  lids  has  also  been 
reported  as  a  result  of  Chloral. 

Chrysarobin  Ointment,  when  applied  to  the 
skin,  may  produce  conjunctivitis  without  secretion. 
When  it  enters  the  conjunctival  sac,  the  inflammation 
which  follows  is  attended  with  profuse  secretion. 

Resorcin  also  causes   conjunctivitis. 

Yellowness  of  the  conjunctiva  is  sometimes 
caused  by  Picric  Acid. 

Epiphora  results  from  the  use  of  Iodine  and 
Iodide  of  Potash. 

Corneal  Anaesthesia  has  resulted  from  the  use 
of  Sulfonal,  Quinine  and  Apomorphia.  The  latter 
produces  also  cloudiness  of   the  cornea. 

Corneal  Softening  has  been  observed  in  Opium 
smokers,  as  a  part  of  the  general  marasmus  thus 
caused. 

Keratitis  has  been  reported  as  an  apparent 
result  of  large  doses  of  Bromide  of  Potash. 

Cataract  has  been  caused  by  Ergotine  and 
Pilocarpine.  The  rapid  development  of  cataract  no- 
ticed during  the  jaborandi  or  pilocarpine  treatment, 
should  teach  caution  in  their  employment  with  elderly 
persons  or  those  with  incipient  cataract.  Opacity  of  the 
crj'stalline  lens  has  been  produced  in  rabbits  by  the 
injection  of  Naphthalin,  and  Menthol  in  lethal  doses 
is  said   to  have  a  similar  eflfect. 


OCULAR  AFFECTIONS  CAUSED  BY  DRUGS.  213 

Glaucoma  sometimes  develops  after  the  use  of 
mydriatics,  especially  Atropin,  hence  the  tension  should 
first  be  tested,  and  any  tendency  to  a  glaucomatous  con- 
dition be  carefully  investigated  before  employing  such 
agents.  Cocaine  applied  persistently  to  the  nasal 
mucous  membrane  has  apparently  precipitated  an  attack 
of  glaucoma,  and  several  cases  following  its  instillation 
into  the  conjunctival  sac  have  been  reported. 


CHAPTER  XI. 

OCULAR    AFFECTIONS    RESULTING  FROM    POISONOUS   SUB- 
STANCES NOT  MEDICINAL,  ADMINISTERED  ACCIDENT- 
ALLY OR  BY  DESIGN,   OR  CONNECTED  WITH 
CERTAIN   EMPLOYMENTS. 

More  or  less  impairment  of  vision  results  from 
the  following  substances : 

Aniline.  "  Misty  Vision  "  has  been  recorded 
as  an  effect  of  poisoning  with  this  substance,  together 
with  mydriasis  and  pigmentation  of  the  cornea  and  con- 
junctiva. 

Arsenic  Persons  employed  in  the  manufacture 
of  wall  paper,  Paris  green,  cosmetics  and  pigments  often 
suffer  from  arsenical  poisoning.  The  Retro-bulbar 
Neuritis  which  it  apparently  causes,  and  to  which 
reference  was  made  in  discussing  toxic  amblyopia,  is 
characterized  by  a  distinct  paracentral  scotoma  for  red 
and  g^een,  and  great  diminution  of  central  vision  with 
preservation  of  the  normal  limits  of  the  periphery  of 
the  visual  field.  The  ophthalmoscope  shows  sector- 
shaped  decoloration  of  the  temporal  portion  of  the  optic 
nerve.  Very  few  cases  of  the  sort  have  been  reported, 
and  the  fact  that  retro-bulbar  neuritis  does  not  seem  to 
exist  among   the   arsenic   eaters  of    Styria    leads   one  to 

(214) 


AFFECTIONS  RESULTING  FROM  POISONS.  215 

question  whether  arsenic  was  the  sole  cause  of  the  vis- 
ual disturbances  attributed   to  it. 

Lead.  Chronic  lead  poisoning  gives  rise  to  a 
variety  of  visual  defects.  Some  are  only  indirectly 
caused  by  the  poison,  being  a  sequence  of  vascular 
changes  in  the  cerebral  vessels,  such  as  sclerosis  and 
peri-arteritis,  of  hemorrhages,  spots  of  softening,  etc.,  or 
of  the  kidney  lesions  which  lead  causes. 

Other  visual  phenomena  are  the  direct  result  of 
the  poison  upon  the  eye  and  the  optic  nerve,  or  upon 
the  visual  centre.  The  indirect  influences  alluded  to 
will  not  be  discussed  here.  The  reader  is  referred  to 
other  portions  of  this  work  for  their  consideration. 

As  direct  result  of  chronic  lead  poisoning  we 
note  : 

1.  Temporary    dimness   of   vision,    and   also  Retro-bul- 

BAR  Neuritis  with  its  characteristic  symptom  of 
cerebral  scotoma.  Both  the  acute  and  chronic 
forms  have  been  recorded  as  due  to  chronic  lead 
poisoning.  The  amblyopia  occurring  with  acute 
lead  poisoning  is  usually  of  uraemic  origin  in 
consequence  of  a  kidney  lesion. 

2.  Neuritis   with   a   diffusely   reddened  and    cloudy  pa- 

pilla, sometimes  with  hemorrhages  and  leading 
later  to 

3.  Atrophy  of   the  optic  nerve  and  complete  blindness. 

4.  Hemianopsia,  concentric  narrowing  of  the  visual 

FIELDS,    color    DISORDERS,    HALLUCINATIONS  and 


216  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

HYSTERICAL     VISUAL     DISTURBANCES     occasionally 

develop. 

Other  symptoms  of  lead  poisoning  will  usually  be 
present  to  establish  the  diagnosis,  such  as  colic,  wrist- 
drop, headache,  etc. 

Saturnine  poisoning  may  result  from  the  inges- 
tion of  food  or  drink  impregnated  with  lead,  by  hand- 
ling paint,  etc.,  by  the  use  of  hair  dyes  and  cosmetics  ; 
and  De  Schweinitz  says :  "  Not  a  few  cases  occur  in 
tailors  and  seamstresses  who  bite  instead  of  break  the 
threads  they  are  using.  These  threads  are  weighted 
with  sugar  of  lead,  which  is  thus  gradually  introduced 
into  the  system.  I  have  seen  one  such  case,  in  which, 
in  addition  to  the  general  lead  toxaemia,  there  was  op- 
tic neuritis." 

NiTROBENZOL  is  used  in  the  manufacture  of 
dyes.  It  has  an  odor  and  taste  very  much  like  that  of 
the  oil  of  bitter  almonds,  and  is  sometimes  used  as  a 
substitute  for  the  latter  in  the  manufacture  of  confec- 
tionery and  in  the  preparation  of  perfumery.  It  pro- 
duces DIMINUTION  of  VISION  and  CONCENTRIC  NARROW- 
ING OF  THE  VISUAL  FIELD  resembling  quinine  amauro- 
sis. A  characteristic  ophthalmoscopic  appearance  ac- 
companying the  amblyopia,  described  by  Litten,  is  a 
darkening  of  the  background  of  the  eye  "as  if  stained 
with  ink "  (see  "  Centralbl.  JiXr  prakt.  AiLgenheilk,"  1891, 
XV,  p.  118).  Sometimes  it  produces  a  central  scotoma. 
Identical   visual  disturbances   are  caused   by    Di-Nitro- 


AFFECTIONS  RESULTING  FROM  POISONS.  217 

BENZOL,  which  is  used  in  the  manufacture  of  explosives, 
especially  "robarite"  and  "  sicherheit." 

Bisulphide  of  Carbon  and  Sulphur  Chlo- 
ride, employed  in  the  manufacture  of  rubber,  cause 
retro-bulbar  neuritis,  as  has  been  already  mentioned. 
The  former  is  the  more  poisonous.  It  is  stated  that  40 
per  cent,  of  the  cases  of  chronic  poisoning  from  this 
substance  have  amblyopia.  The  patient  complains  of 
an  indistinctness  of  vision  as  if  he  were  looking  through 
a  fog.  This  increases  and  a  central  scotoma  with 
intact  boundaries  of  the  field  develops,  reminding  one  of 
tobacco  amblyopia.  The  scotoma  is  most  marked  for 
red  or  green,  and  in  mild  cases  there  may  be  color 
blindness  or  contraction  of  the  color  fields  without 
scotoma.    Monocular  polyopia,  macropsia,  micropsia, 

HEMERALOPIA,     NYCTALOPIA     and     ANAESTHESIA    of     the 

CONJUNCTIVA  and  CORNEA  have  also   been  attributed   to 
the  influence  of  this  poison. 

Exposure  to  the  vapor  of  dilute  Hydrocyanic 
Acid  is  reported  to  have   caused   temporary    amaurosis 

and   HEMIANOPSIA. 

Snake  poison  causes  an  acute  hemorrhagic  dia- 
thesis, and  either  temporary  or  permanent  impairment 
of  vision  may  result  in  consequence  of  hemorrhage  in 
the  retina  or  optic  nerve,  or  in  the  visual  centres. 
Amaurosis  after  snake  bites  is  said  to  be  of  common 
occurrence  in    Brazil. 


218  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

Methyl  Alcohol,  obtained  by  the  destructive 
distillation  of  wood,  a  by-product  in  the  manufacture 
of  charcoal,  and  used  as  a  solvent  for  resins  and  in  the 
manufacture  of  aniline  dyes,  has  caused  blindness 
within  twenty-four  hours  of  its  administration,  according 
to  Mengin.     {''Rec.  d'Ophth.,"  1879,  P-  663). 

Mercury  causes  loss  of  vision  due  to  hemor- 
rhages, fatty  degeneration  and  inflammation  of  the 
retina  and  optic  nerve,  resembling  retinitis  albuminu- 
rica. 

Phosphorus,  used  in  the  manufacture  of  matches, 
etc.,  causes  very  similar  pathological  conditions  to  those 
resulting  from  mercury,  and  with  corresponding  visual 
disorders. 

Lids.  Oedema  and  Eczema  of  the  lids  is 
caused  by  Arsenic.     The  skin  is  often  dry  and  scaly. 

A  bluish  color  of  the  skin  of  the  lids  is  caused 
by  Nitrate  of  Silver. 

Conjunctiva.  Inflammation  and  ulceration 
of  the  conjunctiva  is  also  caused  by  Arsenic.  It  occa- 
sions a  brownish-red  coloration  of  that  membrane, 
especially  noticeable  in  workers  in  artificial  flowers. 
The  bluish  hue  noticed  upon  the  skin  of  the  lids  in 
nitrate  of  silver  poisoning,  is  also  seen  upon  their  inner 
surfaces.  Aniline  causes  a  brownish  color  of  the  con- 
junctiva and  cornea,  and  a  jaundiced  appearance  results 
from  Phosphorus. 


AFFECTIONS  RESULTING  FROM  POISONS.  219 

Paralysis  of  one  or  more  of  the  external  eye 
muscles,  of  the  iris  and  ciliary  muscle,  and  of  the  lid 
may  be  an  accompaniment  of  L<ead  poisoning.  The  fol- 
lowing case  reported  by  Bach,  of  Wurzburg,  in  the 
"  Arcliiv  fur  AugenJdelkunde,'^  April,  1893,  is  interesting 
and  suggestive.  The  patient  had  exhibited  symptoms 
of  lead  poisoning  for  some  time,  and  the  ocular  condi- 
tion was  regarded  as  another  manifestation  of  the  same 
toxaemia.  The  pupils  were  irregular,  and  there  was 
absence  of  the  usual  reflex  contraction  with  convergence 
and  accommodation  and  upon  the  stimulus  of  light. 
The  reflex  dilatation  attending  stimulation  of  the  sym- 
pathetic was  preserved.  The  visual  field  for  white  was 
normal,  but  was  contracted  for  red  and  green.  There 
was  some  protrusion  of  the  right  eye  suggestive  of 
Basedow's  disease.  There  was  paralysis,  more  or  less 
complete,  of  the  rectus  internus,  superior  and  inferior, 
and  of  the  levator  of  the  upper  lid  of  the  fight  eye, 
and  slight  paresis  of  the  external  rectus  of  the  left  eye. 
De  Schweinitz  asserts  that  the  external  rectus  w  more 
frequently  affected  than  any  other  of  the  ocular  mus- 
cles. 

Nystagmus  sometimes  accompanies  poisoning  by 
Arsenic,  Lead  and  Benzine. 

Pupil.  Cyanide  of  Potash  (used  in  photog- 
raphy) and  Hydrocyanic  Acid  cause  enormous  dilata- 
tion and  immobility  of  the  pupils,  associated  with 
slight    exophthalmus,  swelling   of  the   upper   lid,  and   a 


220  THE  EYE  AS  AX  AID  IN  GENERAL  DIAGNOSIS. 

peculiar  staring   expression.     Mydriasis  also  results  from 
Aniline,  Bisulphide   of   Carbon,   Nitrobenzol  and 

Dl-NITROBENZOL. 

Iritis  has  been  caused  by  Fuchsin  and  Ani- 
line. 

Vitreous  opacities  occur  in  arsenical  poison- 
ing, and  according  to  Wolfe  (see  "  British  Medical 
Journal,"  1879,  II,  p.  328)  from  excessive  TEA  drinking. 

Retinal  hemorrhages  are  caused  by  Aniline, 
Phosphorus,  Carbonic  Acid  Gas,  Lead,  Mercury, 
Nitrobenzol  and  Snake  Poisoning.  With  aniline 
and  nitrobenzol  the  blood  is  very  dark.  With  the  for- 
mer the  fundus  appears  as  if  filled  with  ink. 


CHAPTER  XII. 

OCULAR    AFFECTIONS    DUE    TO    POISONOUS  SUBSTANCES 
CONTAINED   IN   CERTAIN   ARTICLES   OF   FOOD   AND 
DRINK.      A  :    FUNGUS   POISONING.     B  :    PTO- 
MAINE  POISONING.      OCULAR   SYMP- 
TOMS   ATTENDING    AND     FOL- 
LOWING  ANAESTHESIA. 

A.  Fungus  poisoning.  Certain  varieties  of  mush- 
rooms are  poisonous,  and,  in  addition  to  the  gastro-in- 
testinal  disturbances  and  other  toxic  manifestations,  give 
rise  to  the  following  eye  symptoms  which  may  occasion- 
ally serve  as  an  aid  to  an  understanding^  of  the  systemic 
affection,  and  of  the  species  of  fungus  which  is  the 
exciting  cause. 

Pupillary  phenomena  are  among  the  most  fre- 
quent of  such  symptoms. 

Mydriasis  follows  the  ingestion  of  some  varieties 
of  fungi  belonging  to  the  genus  Morchella,  and  it  is 
usually  accompanied  with  paresis  of  accommodation. 

Myosis  and  spasm  of  accommodation  attend 
poisoning  with  certain  varieties  of  Agaricus,  a  genus 
of  mushroom  embracing  over  a  thousand  species,  many 
of  which  are  edible.  The  poisonous  varieties  contain 
muscarine  which  occasions  the  ocular  symptoms. 

(221) 


222  THE    EYE    AS    AN    AID    IN   GENERAL    DIAGNOSIS. 

Visual  hallucinations  are  also  symptomatic  of 
fungus  poisoning  and  amblyopia  without  organic 
changes  in  the  fundus  has  been  obsers'ed. 

Hemorrhages  and  fatty  degeneration  of 
the  Retina  are  occasional  manifestations  of  the  same 
toxaemia. 

B.  Ptomaine  poisoning.  By  this  term  is  under- 
stood the  effects  produced  by  the  ingestion  of  toxic  sub- 
stances developed  in  animal  tissues  and  secretions  dur- 
ing the  process  of  decomposition.  Ptomaines  are  pro- 
duced through  the  agency  of  micro-organisms.  They 
are  the  virus  of  the  bacteria  of  putrefaction,  and  are 
found  in  the  early  stages  of  decomposition,  sometimes 
before  such  a  condition  is  perceptible  to  the  senses. 
They  develop  notably  in  mussels,  oysters,  eels  and  other 
varieties  of  fish,  also  in  sausage,  ham,  mutton,  veal, 
beef,  canned  meats,  and  in  milk  and  articles  made  from 
milk,  as  cheese,  custard  and  ice-cream.  However  caused, 
the  phenomena  of  ptomaine  poisoning  are  very  similar. 
Such  poisoning  is  often  serious  and  sometimes  fatal. 
Typhoid  fever  is  sometimes  closely  simulated. 

The  ocular  symptoms  of  ptomaine  poisoning  are 
similar  to  those  mentioned  under  fungus  poisoning. 

Congestion  of  the  conjunctiva  attends  acute  pto- 
maine poisoning. 

Paralysis  and  paresis  of  the  levator  of  the  upper 
lid    (ptosis),  and    of    the    external    ocular   muscles  some- 


OCULAR  AFFECTIONS  DUE  TO  POISONOUS  SUBSTANCES.      223 

times  occur.  Such  symptoms  are  usually  of  nuclear 
origin  and  suggest  hemorrhage  or  meningitis. 

Mydriasis  and  paresis  of  accommodation  usually 
attend  ptomaine  poisoning,  and  thus  are  of  diagnostic 
importance.  They  are  among  the  typical  symptoms  of 
poisoning  by  bad  meat.  They  may  be  the  only  symp- 
toms in  mild  cases,  and  are  frequently  overlooked.  The 
mydriasis  is  always  bilateral.  Paresis  of  accommodation 
may  occur  without  dilatation  of  the  pupil. 

Myosis  and  spasm  of  accommodation  attend  poi- 
soning from  neurine,  a  ptomaine  found  in  putrefying 
fish. 

Vision  is  not  disturbed  as  a  rule,  although  am- 
blyopia has  been  noticed. 

Some  fishes  are  poisonous  only  at  certain  times 
and  under  certain  conditions,  when  they  may  give  rise 
to  symptoms  of  ptomaine  poisoning.  The  toxic  element 
may  reside  only  in  special  organs,  as  the  liver  and  sex- 
ual glands,  or  may  be  dependent  upon  the  kind  of  food 
which  they  have  eaten.  Decomposing  haddock  contains 
muscarine,  and  causes  symptoms  identical  with  those  at- 
tending agaricus  poisoning.  De  Schweinitz  explains 
many  of  the  symptoms  of  ptomaine  poisoning  by  the 
statement  that  "  many  ptomaines  are  basic  compounds, 
closely  simulating  the  vegetable  alkaloids,  such  as  nico- 
tine, atropin,  veratrine  and  strychnine,"  and  he  adds, 
"consequently    the    ocular    symptoms    which    may   arise 


224         THE   EYE   AS   AN   AID   IN  GENERAL   DIAGNOSIS. 

under  their  influence  are   similar  to  those  which  the  al- 
kaloids themselves  produce." 

OCULAR  CONDITIONS  ATTENDING  AND  FOLLOWING 
ANAESTHESIA. 

The  behaviour  of  the  pupil  during  anaesthesia 
from  chloroform  is  important,  and  should  be  understood 
and  carefully  noticed,  as  it  affords  a  valuable  indication 
of  approaching  danger. 

During  the  early  stage,  before  narcosis  is  com- 
plete, the  pupil  is  dilated  and  responsive  to  light.  In 
the  stage  of  complete  insensibility,  the  pupils  are  con- 
tracted and  the  eyeballs  are  fixed.  Dilatation  with  re- 
action to  light  returns  with  returning  consciousness. 
Dilatation  during  narcoses  indicates  a  necessity  for  cau- 
tion. 

Sudden  dilatation  dunng  complete  anaesthesia  is  an 
indication  of  impending  asphyxia.  The  inhalations  should 
be  at  once  discontinued  and  every  effort  made  to  stimu- 
late respiration  and  to  avert  imminent  death.  The  con- 
comitants of  this  form  of  dilatation  serve  to  differentiate 
it  from  that  previously  mentioned,  and  to  emphasize  the 
danger  attending  it.  They  are :  i,  profound  narcosis  in 
distinction  from  commencing  narcosis  or  recovery  from  it ; 
2,  absence  of  conjunctival  and  all  other  reflexes,  instead 
of  the  presence  of  contraction  upon  the  stimulus  of 
light    and  of  other  reflexes ;   3,  stertorous  respiration  in 


OCULAR  AFFECTIONS  DUE  TO  POISONOUS  SUBSTANCES.      225 

distinction  from  shallow  respiration   and   efforts  at  vom- 
iting; 4,  fixed,  immovable  eyeballs,  instead  of  mobile. 

Arthur  Ward,  in  the  "  London  Lancet,"  for  July 
28,  1896,  offers  the  following  explanation  of  the  pupil- 
lary phenomena :  He  considers  the  primary  dilatation 
due  to  reflex  inhibition  of  the  unaffected  third  nerve 
centre  induced  by  mental,  sensory  or  sympathetic  in- 
fluences acting  upon  the  semi-narcotized  cerebrum. 
Dilatation  he  considers  due  to  reflex  inhibition.  In 
complete  narcosis,  the  cerebrum  is  no  longer  capable  of 
receiving  or  transmitting  peripheral  impressions,  but  the 
third  nerve  centre  still  controls  the  pupil.  In  profound 
and  dangerous  narcosis,  the  third  nerve  centre  is  also 
narcotized  and  no  longer  controls  the  pupil  which  di- 
lates and  grows  insensitive  to  light,  and  the  globe  be- 
comes fixed.  When  the  narcosis  is  not  very  profound, 
the  contracted  pupils  will  dilate  after  cutaneous  irrita- 
tion or  when  the  patient  is  loudly  called. 

Ether.  Contraction  is  the  rule  during  ether  narco- 
sis. In  1 200  inhalations  Jacob  (Jahrbuch  fiir  Augenheil- 
kunde,  ^^879,  p.  229)  observed  mydriasis  only  six  times. 

Ethyl  Chloride  has  produced  long-continued 
dense  corneal  opacities  due  solely  to  oedema. 

Ethyl  Bichloride.  Acute  glaucoma  has  fol- 
lowed anaesthesia  from  this  agent,  associated  with  opac- 
ity of  the  cornea,  but  with  slight  external  signs  of  in- 
flammation. 


15 


226  THE   EYE   AS   AN   AID    IN   GENERAL   DIAGNOSIS. 

Ethyl  Nitrite  produces  dilatation  and  immo- 
bility of  the  pupils. 

Nitrous  Oxide.  Extreme  myosis  attends  the 
coma  caused  by  inhalation  of  this  gas.  It  also  causes 
agreeable  visual  hallucinations.  Dilatation  of  the  reti- 
nal arteries  and  extreme  redness  of  the  papilla  has  been 
observed. 


CHAPTER  XIII. 

BIBLIOGRAPHY. 

The    following    is    a    partial    list    of    authors  and 
publications  consulted  in  the  preparation  of  this  treatise. 

"AMERICAN  JOURNAL  OF  OPHTHALMOLOGY." 
"  ANNALES  D'OCXJLISTIftUE." 
ANTONELLI : 

"Archives  de  Neurologia.''     Paris,  Nov.,  1893. 

"ARCHIVES  OF  OPHTHALMOLOGY."     (KNAPP  &  SCHWEIGGER). 
ANDROGSZY,  OF  ST.  PETERSBURG: 

Zehender's    "  Klinische   Monatsblatter  fiir   Augen- 
heilkunde."     Stuttgart,  Vol.  32,  p.  263,  1894. 

ARNDT : 

"  System  of  Medicine." 

BULL: 

"  Trans.  American  Oph.  Soc."  and  N.  Y.  "Medical 
Journal,"  August,  1893. 

BACH,  LUDWIG : 

Knapp's  "  Archives,"  January,  1895. 

BERRY : 

"  Trans.  Oph.  Soc."  United  Kingdom,  Vol.  VII,  p. 
91. 

"BERLINER  KLIN  WOCHENSCHR." 
BACH,  OF  WURTZBURG  : 

"  Archiv  fiir  Augenheilkunde,"  April,   1893. 
(227) 


228  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

BEBGEB,  E. : 

"La  Medecine  Moderne,"  Nov.  21,  1895. 

BAEEB,  OF  SAN  DIEOO : 

"Southern  Cal.  Prac,"  January,  1893. 

BAEEB,  OF  UTICA : 

"  American  Journal  of  Insanity,"  April,  1893. 

BBOWNE,  LENNOX : 

"Diseases  of  the  Nose  and  Throat." 

BUBNETT: 

"  System    of   Diseases    of    the    Eye,    Nose     and 
Throat." 

COBTE : 

"  Deutsche  Med.  Woch.,"  January  23,  1891. 

CLAIBOBNE : 

"Medical  Record,"  August  14,  1894. 

DE  SCHWEINITZ : 

"  Toxic  Amblyopias,"  1896. 
"       "  Transactions  of  the  American  Ophthalmological 
Society  "  for  1891,  p.  23. 

BOWLING  : 

"Quarterly  Journal  of  Inebriety"  for  January,  1893. 

"  EYE,  EAB  AND  THBOAT  JOUBNAL." 
ELSELINO,  OF  OBATZ: 

"  Fortschritt.  der  Medicin."     Berlin,  Dec,  1892. 

FTTCH8 : 

"  Text-book  of  Ophthalmology." 

FOX,  WEBSTEB: 

"Medical  Bulletin." 


BIBLIOGRAPHY.  229 

TOSTER : 

"Text-book  of  Physiology." 

GOWERS : 

"Diseases  of  the  Nervous  System." 

OALEZOWSKI : 

"Jahrb.  f.  Aug.,"  1883,  p.  297. 
On    Hereditary   Ocular    Syphilis.      "Transactions 
of  Dermatology  and  Syphilography."    Paris,  Nov. 
15,   1895. 

ORUBER : 

"Diseases  of  the  Ear."     Translation.     2nd  Amer- 
ican Edition. 

GATTI,   E. : 

"Gaz.  degli  Ospital,"  1880,  I,  p.  4. 

GRAY: 

"  Anatomy." 

GOODNO : 

"  Practice  of  Medicine." 

HOWE: 

"American  Journal  Ophthal.,"  Vol.  II,  5-6,  1885. 

HANGG : 

"  Dis."  Strasbourg,   1890. 

HENSCHEN  : 

"  Klinische  und  Anatomische  Beitrage  zur  Patho- 
logic des  Gehirns."     Upsala,   1892. 

HUTCHINSON  : 

"  Centralblatt  fur  Augenheilkunde,"  August,  1887, 
p.  240. 


230  THE  EYE  AS  AN  AID  IN  GENERAL  DIAGNOSIS. 

HULANICKI,  OF  ST.  FETEBSBUBO  : 

"  Medicinische  Wochenschrift.,"  June,  1893. 

HEBBEH,  OF  JACKSON : 

"  Ophthalmic  Record,"   January,   1893. 

HAMMOND  : 

"  Diseases  of  the  Nervous  System." 

"JOHN  HOPKINS  HOSPITAL  BULLETIN,"  Baltimore. 
JACOB : 

"  Jahrbuch  fiir  Augenheilkunde,"    1879,  p.  229. 

JENNINGS : 

"  Color  Vision  and  Color  Blindness." 

"JOUBNAL  OF  OPHTHALMOLOGY,  OTOLOGY  AND  LABYNGOLOGY." 
JTJLEB: 

"  Ophthalmic  Science  and  Therapeutics." 

KNIES : 

"  The  Eye  in  General  Diseases." 

LA  OBANOE: 

"Arch.  d'Ophthalm.,"  January,  1887. 
"       "  Medical   and   Surgical  So.,"    Bordeaux,   Novem- 
ber, 1894. 

LETTIN  : 

"Centralbl.    for   prakt.    Augenheilk.,"   1891,  XII, 
p.   118. 

LEWIS,  E.  PABK : 

"  Eye,  Ear  and   Throat  Journal,"  January,  1895. 

LOPEZ : 

"Archiv.  f.  Aug.,"    XXII,  2  and  3. 

LOBIKO : 

"Text-book  of  Ophthalmoscopy." 


BIBLIOGRAPHY.  231 

MARFLE : 

"New  York  Medical  Record,"  March  ii,  1893. 

MILLS,  CHAS.  K. : 

"  International  Clinics,"  October,   1895. 

MOTT  : 

"International  Clinics,"  1895,  Vol.  I,  p.  127. 

MEN6IN : 

"Rec.  d'Ophth.,"    1879,  p.  663. 

MILES : 

"Weekly  Medical  Review,"   1884. 

MADDOX : 

'■' Ophthalmological  use  of  Prisms." 

MUSEHOLD  : 

"  Deutsche  Medicinische    Wochenschrift,"  Febru- 
ary, 1892. 

MAUTHNER : 

"  Sympathetic  Diseases  of  the  Eye." 
"       "Gehrin  und  Auge." 

"  NEW  YORK  MEDICAL  JOURNAL,"  1893. 
NOYES : 

Editorial    note    in    Knies'    "  The  Eye  in  General 
Diseases." 
"       "  Diseases  of  the  Eye,"  p.  683. 

NORRIS  AND  OLIVER : 

"  Text-book  of  Ophthalmology." 

NORTON : 

"  Ophthalmic    Diseases  and  Therapeutics." 

OLIVER : 

"Medical  News,"  November  11,   1893. 


232  THE  EYE  AS  AX  AID  IX  GEXERAL  DIAGXOSIS. 

D'OENCH : 

"N.  Y.  Medical  Record,"  July  14,  1894. 
"       "Ophthalmic  Review." 

OSLEB : 

"  Practice  of  Medicine." 

OLIVEB,  CHAS.  A. 

"Ophthalmic     Methods    for     the    recognition     of 
Nerve  Disease." 

FISCHL . 

"  Medical  News,"  July  20,   1893. 

BANDOLFH : 

"Johns    Hopkins    Hospital   Bulletin,"    June   and 
July,  1893. 

EANNEY,  OF  NEW  YORK  : 

"  Medical  Record,"  May  12,   1894. 

BOOSA,  ST.  JOHN : 

"Treatise  on  the  Diseases  of  the  Eye." 

SABBAZES : 

"  Semaine  Medic,"  September  26,   1894. 

SEMELINO : 

"Charite  Annal.,"  XI,  p.  389. 

8TEWABT,  OF  CINCINNATI  : 

"  Eye,  Ear  and  Throat  Journal." 
sous : 

"Journal  de  Medecine  de  Bordeaux,"  Nov.,  1893. 

8ILEX : 

At  Medical    Society  of    Berlin,  January  23,   1895, 
reported  in  "Annales  d'Oculistique." 


BIBLIOGRAPHY.  233 

TJHTOFF : 

Graefe's  "  Archives,"  Bd.  XXXII,  et.  al,  (p.  3,  p. 
6b). 

VIALET : 

"Annales  d'Oculistique."     Paris,  April,   1894. 

VERRAY ; 

"  Rev.  Med.  de  la  Suisse  Romande." 
WOLFE : 

"British  Medical  Journal,"   1879,  I^j  P-  328. 

WARD,  ARTHUR : 

"  London  Lancet,"  July  28,   1896. 
WHITE : 

"  Medical  News,"  July  15,   1893. 

WOOD; 

"N.  Y.  Medical  Journal,"   July  7  and  14,  1894. 

WHITE,  OF  RICHMOND  : 

"  Burnett's  Treatise  on  Diseases  of  Ear,  Nose  and 
Throat." 
WHITE,  JOSEPH: 

"  London    Medical    Press   and    Circular,"   March, 
1894. 

ZIMMERMANN,  OF  MILWAUKEE: 

Knapp's  "  Archives,"  January,   1895. 


INDEX. 


A  BADIE'S  Sign, 14 

Abdominal    Growths, 11 

Abscess  of  Brain, 99,  loi 

Accommodation,  Behavior  of, 58 

Accommodation,  Disorders   of,  ...         78,   156,  211,  221,  223 

Accommodation,  Spasm  of 158 

Addison's  Disease, iii  23 

Agraphia 125 

Albuminuria, 57)  89,  90,  loi 

Albuminuric  Retinitis, 90 

Alcoholism, 70,  74,  76,  79,  198 

Alexia, 125 

Alternating  Paralysis, 36,  37 

Amaurosis 122,  123,  124,  185,  200,  217 

Amblyopia, 122,  185 

Amblyopia,  Alcoholic 191-198 

Amblj'opia,  Crossed,  .         .         .         .         .         .         .         .         .121 

Amblyopia,  Drug  Effects,  .......        200-210 

Amblyopia  Due  to  Poisons,       .......        214-218 

Amblyopia,  Hysterical, 160-165,  216 

Amblyopia,  Monocular, 160,  162 

Amblyopia,  Tobacco, 191-198 

Amblyopia,  Tobacco,  Differential  Diagnosis  of,      .        .       196,  197,  198 

Amblyopia,    Toxic, 107,  1S9-199 

Amblyopia,  Toxic,  Pathology  of, 195,  196 

Amblyopia,  Toxic,  Symptoms  of, 195 

Amblyopia,  Transient,        .  .         .         .         .         .         .         .122 

Anaemia, 83,  87,  123 

Anaemia  of  Brain, 150 

Anaemia,  Pernicious, 88,  92 

Anaesthesia  of  Conjunctiva, 106,  153,  159,  217 

Anaesthesia  of  Cornea, 25.  '59.  212,  217 

Anaesthesia  of  Lids, 11.  I3i  ^59 

(235) 


236  INDEX. 


Anaesthesia,  Ocular  Conditions  Attending  and  Following,  .  224 

Aneurism  of  Aorta  and  Art.  Innom., 66,  85 

Aneurism  of  Internal  Carotid, 22 

Aneurism  of  Orbital  Artery, 22 

Angular  Gyrus,  Affections  of .122 

Angina i^ 

Anisocorea, -- 

Aorta,  Aneurism  of, 66    8s 

Aortic  Insufiiciency, 3- 

Apoplexy, 37,  38.  7°.  74.   loi.  119 

Apoplexy  Cerebral,  Deviation  of  eyes  in,  ....  37,  38 

Argyll-Robertson  Pupil 62,  72,  105 

Arsenic, .199 

Art.  Innom.  Aneurism  of 66   85 

Arterio-Sclerosis, gg 

Associate  Paralysis,  "8    10 

Ataxia,  Hereditary  (Friedreich's  Disease), 52 

Atheroma, 20,  86 

Atrophy  of  Optic  Ner\'e,  .         .         .104,   105,  106,  107,   195,  196,  215 
Aural  Ocular  Reflexes, igc 

DASALAR  Paralysis, •        •        35 

Basedow's  Disease, 14,  22,  39 

Base  of  Brain,  Diagram  of, 30 

Binocular  Vision,  Requisites  for 145^  i^g 

Bisulphide  of  Carbon, joq 

Blindness,  Monocular 100^  123,  160 

Blindness,  Significance  of,         .....         .       log^  igS 

Blindness,  Simulated,  Method  of  Detecting,  ....        160-162 

Blue  Color  of  Lids, 218 

Brain,  Abscess  of, 99,  loi 

Brain,  Anaemia  of, jco 

Brain,  Compression  of 70 

Brain,  Concussion  of, 70 

Brain,  Hyperaemia  of, 74 

Brain,  Tumor  of, 70,  99,  100,   loi,  102,  105 

Bright's  Disease, qi 

Bums  of  Skin 87,  88 

r^ALCARINE  Fissure, 113 

Cannabis  Indica, lo^ 


INDEX.  237 

Carbon  Bisulphide, 199 

Caries  of  Orbit, 21 

Carotid,  Internal,  Anuerism  of, 22 

Cataract,      .         . 54,  55,  212 

Catarrh,  Nasal 18 

Cerebellum,  Disease  of, 70 

Cerebral  Embolism, 70 

Cerebro-spinal  Meningitis,         .        .         .         .  .     50,  70  74,  102 

Chiasm,  Affections  of, 118 

Chiasm,  Optic, no 

Chloral, 199 

Chloroform, 74 

Chlorosis, 83,  88 

Cholera, 20,  24,  25,  71 

Choked  Disc, 99.  ^00,  loi,  102,  103,  105 

Choked  Neuritis, 100 

Chorea, 16,  154,  155 

Chorea,  Hypermetropia,  Frequency  with, 155 

Choroid,  Affections  of, 82 

Choroiditis,  Metastatic  Suppurative, 83 

Cilio-Spinal  Centre 63,  66 

Color  Blindness, 209 

Color  Fields,  Chart  of, ii5 

Colored  Vision, 208,  209 

Coma,  Syphilitic, 7^ 

Compression  of  Brain, 7o 

Concussion  of  Brain, 7° 

Concussion  of  Spine io3 

Congestion,  Spinal 66 

Conjugate  Paralysis, 37i  38,  4i 

Conjunctiva,  Affections  of, ^8,  104,  218 

Conjunctiva,  Anaesthesia  of, 106,  153,  159,  217 

Conjunctiva,  Hemorrhage  of, 20 

Conjunctiva,  Leprosy  of, 21 

Conjunctiva,  Oedema  of, 20 

Conjunctiva,  Tuberculosis  of 20 

Conjunctiva,  Xerosis  of, 25 

Conjunctivitis, 211,  212,  218,  222 

Conjunctivitis,  Croupous, ^9 

Conjunctivitis,  Diphtheritic, '9 

Conjunctivitis,  Phlyctenular, 18,  19 

Convulsions,  Infantile, 54 


238  INDEX. 

Cornea,  Affections  of, 23,  212,  218 

Cornea,  Anaesthesia  of 25,  159,  212,  217 

Cornea,  Leprosy  of, 26 

Corpora  Quadrigemina,  Affections  of 40 

Corpora  Quadrigemina,  Function  of in 

Corpus  Striatum,  Affections  of 40 

Cortical  Paralysis, 36,  41,  42,  43 

Cortical  Visual  Disorders,  38,  42,  113,  119,  120,  121,  122,  123,  126,  167 

Creosote,      . 199 

Crossed  Amblyopia, 121 

Crura  Cerebri,  Affections  of, 3^,  37 

Cuneus, 113,  120 

r\ALRYMPLE'S  Sign 14 

Death,  Signs  of, 23,  26 

Dementia 105 

Dementia  Paralytica,  .68,  71,  73,  75,  77,  104,  105,  125 

Dental  Ocular  Reflexes 180,  185 

Diabetes,     .        .  12,  19,  24,  47,  55.  57,  79,  §7.  89,  92,  97,  99,  loi,  124 

Diabetic  Conjunctivitis 19 

Diabetic  Iritis, 57 

Diabetic  Retinitis, .         .        99 

Digestion,  Disorders  of, 12,  16 

Diphtheria 19.  35,  47,  79 

Diplopia, 209 

Diplopia,  Monocular, 162 

Diseases,    A  Tabulated   Statement  of,    with    Characteristic   Eye 

Symptoms 127-140 

Dissociate  Paralysis, 43 

Drugs,  Disorders  of  Vision  due  to,  200  to  210 

Drugs,  Effects  in  Amblyopia,  .....  200  to  210 

Drugs,  Pupillary  Phenomena  due  to, 210,  211 

Dyslexia, 125 

CCZEMA  of  Lids, 12,  218 

Embolism,  Cerebral 70 

Embolism  of  Central  Retinal  Artery, 86 

Encephalitis 123 

Endocarditis 86 

Epilepsy, 78,  122,  I47-IS4 

Epilepsy,  Behavior  of  Pupil  in, 153 


INDEX. 


239 


Epilepsy,  Eye  Symptoms  During  Attack, 153 

Epilepsy,  Influence  of  Eye-Strain  in  Causing,        .        .         .  147-152 

Epilepsy,  Visual  Aurae  in, 149^  150 

Exophthalmic  Goitre 14,  IS 

Eye,  Nervous  Anastomoses  Between  Nose  and  Teeth  and,  .  .       180 

Eye-ball,  Protrusion  of, 22,  219 

Eyes,  Deviation  of,  in  Cerebral  Apoplexy,  Etc 37,  38 

Eye-strain  a  Cause  of  Headache 166-169 


CEVER,  Intermittent,     . 

Fever,  Puerperal, 
Fever,  Scarlet,    . 
Fever,  Typhoid, 
Field  of  Vision  for  Color, 
Field  of  Vision,  Method  of  Examination, 
Field  of  Vision,  Normal  Boundaries  of. 
Fifth  Nerve,  Irritation  of,        .         .         . 
Friedreich's  Disease  (Hereditary  Ataxia), 
Fundus,  Ophthalmoscopic  Appearance  of, 
Fungus  Poisoning 


83 

83 

104 

83,  104 
"5 

16,  117 
114 

t7,  184 

52 
80 
221,  222 


/GENICULATE  Bodies?,  External, in 

^^    Glaucoma, 184,  185,  213,  225 

Goitre,  Exophthalmic, I4i  i5 

Gonorrhoea, 57 

Gonorrhoeal  Iritis 57 

Gout 98 

Gouty  Retinitis, 98 

Gratiolet,  Optic  Radiation  of in,  119,  120 

OALLUCINATIONS,  Visual,  .         .       118,  119,  124,  208,  215,  222 

Headache  Caused  by  Eye-Strain, 166-169 

Heart  Disease, 12,  85,  86 

Hemeralopia, 217 

Hemianopsia, 42,  68,  113,  117,  209,  215,  217 

Hemianopsia,  Homomymous, iiS 

Hemianopic  Pupillary  Inaction  (Wernicke's  Sign),      ...        68 

Hemorrhage,  Cerebral, 37,  38,  70,  74,  loi,  119, 

Hemorrhage  of  Conjunctiva 20 

Hemorrhage  of  Retina, 86,  220,  222 

Hemorrhages,  Sequence  of loi 


240  INDEX. 

Hepatic  Disease, 1 1 1  23 

Hippus 77 

Hydraemia, 12 

Hydrocephalus, 70,  100,  loi 

Hyperaemia  of  Brain,  74 

Hyperaemia  of  Retina 85 

Hyp)ennetropia,  Frequency  with  Chorea, 155 

Hypertrophy  of  Left  Ventricle, 83 

Hysteria 53.  78,  123,  157,  159 

"Hysteria,  Behavior  of  Pupil  in, 159 

Hysteria,  Disorders  of  Sensation  in,  ...  •        •       I59 

Hysteria,  Muscular  Disorders  in 17,  158 

Hysteria,  Vaso-Motor  Disorders  in,  .       •.  .       160 

Hysteria,  Visual  Fields  in, 162,  165 

Hysterical  Amblyopia, 160-165.  216 

Hysterical  Eye  Symptoms,  General  Features  of,  .  .       157 

Hysterical  Paralysis, 158 

Hysterical  Ptosis,  17,  15S 

IDIOCY 105 

Infantile  Convulsions, •      .        54 

Infectious  Diseases, 87,  194 

Inflammation  of  Optic  Nerve,  102,  103 

Influenza, 194 

Inherited  Syphilis, 24,  96,  147 

Insanity, 68,  71,  73,  75,  77,  114,  124,  125,  169 

Insomnia 170 

Intermittent  Fever 83 

Intra-Cerebral  Paralysis, 36 

Iodoform, 199 

Iris,  Affections  of, 55.  219,  220 

Iritis,  Diabetic, 57 

Iritis,  Gonorrhoeal 57 

Iritis,  Leprous 56 

Iritis,  Rheumatic, 57 

Iritis,  Syphilitic, 55.  S6 

Iritis,  Tuberculous, 56 

Irritation,  Spinal, 66 


I^ERATITIS,  Malarial 25 

Keratitis,  Neuro-paralytic, 24 


INDEX.  241 

Keratitis,  Parenchymatous, 23 

Kidney,  Diseases  of,           .         .         .         .         il,  47,  86,  89,  90,  92,  124 
Knies'  Sign, 69 

I  ABOR,  Premature,  Indications  for  Induction  of,        .         .         .         93 
Lagophthalmus,  .         .........         14 

Lead,  Poisoning  by, 87,  194,  199 

Leprosy  of  Conjunctiva, 21 

Leprosy  of  Cornea, 26 

Leprosy  of  Iris, '56 

Leprosy  of  Lids, 13 

Leukaemia, 92,  97,  loi 

Leukaemia  Retiniitis,  .........         97 

Lids,  Affections  of Ii,  15,  16,  17,  158,  219 

Lids,  Anaethesia  of, 11,  13,  159 

Lids,  Blue  Color  of, 218 

Lids,  Eczema  of, 12,  218 

Lids    Leprosy  of,        .         .         .         .•        .         .         .         .         .         .         13 

Lids,  Oedema  of, 11,  12,  218 

Lids,  Paralysis  of, 17 

Lids,  Pigmentation  of  Skin  of, Ii 

Lids,  Swelling  of, 211,  219 

Lids,  Tremor  of 15.  211 

Lids,  Tuberculosis  of, 13 

Light  Reflex, 61,  69,  ii8 

Locomotor  Ataxia  (Tabes),  n,  14,  17,  25,  44,  45.  46,  66,  71,  73. 

75.  76,  77,  104,  105,  106,  112,  198 
Local  Ocular  Reflex  Neuroses '  •         .165 


M 


ACROPSIA 217 

Malaria,      .......          25,  87,   103,   104,  123 

Malarial  Keratitis 25 

Measles, ^94 

Memory  Centre,  Nothnagel's, 120 

Meningitis, 20,  83,  99,   103,   105,  123 

Meningitis,  Cerebro-spinal, .SO.  7o,  74.  102 

Meningitis,  Pachy-hemorrhagica, loi 

Meningitis,  Spinal, 66 

Meningitis,   Tubercular,     .         .         43.  50.  7o,  7h  7^,  83,  loi,  102,  119 

Menstruation,  Disorders  of, 11,  12,  86,  194 

Metastatic  Suppurative  Choroiditis, 83 

16 


242  INDEX. 

Methods  of  Estimating  Acuity  of  Vision 108,  109 

Micropsia 209,  217 

Migraine, 167,  168 

Migraine  Ophthalmic, 167 

Monocular  Blindness, 109,  123,   160 

Monocular  Diplopia, 162 

Monocular  Mydriasis,  .         .  .      "  .         .         ,         •  68,  69 

Monocular  Polyopia, 217 

Morning  Ptosis,  16 

Multiple  Sclerosis 47,  52,  78,  79,  104,  105 

Muscles,  External  Ocular,  Affections  of,        .        27,  158,  159,  172,  219 

Muscles,  Spasmodic  Affections  of 14,  38,  42,  49-53 

Muscular  Disorders  in  Hysteria 17,  158 

Mydriasis, 210,  219,  220,  221,  223 

Mydriasis,  Monocular 68,     69 

Mydriasis,  Paretic, 65,     67 

Mydriasis,  Spastic, 64,  66,     67 

Myelitis, 107 

Myosis, 74,  198,  211,  221,  223 

Myosis,    Paretic, 74,  105 

Myosis,  Spastic, 74 


jVJARCOSIS, 74 

*^     Nasal  Catarrh, 18 

Nasal  Ocular  Reflexes, 180-185 

Nausea, 170 

Nephritis, 11,  89,  90,  92,  124 

Nerves,  Motor  of  Eye,  Origin  and  Course  of 27 

Nerve,  Third,  Nuclei  of  Origin  of,  ......         28 

Neurasthenia i55-»57,   158,  17' 

Neurasthenia,  Eye  Symptoms  in, 156 

Neuritis,  Choked, 100 

Neuritis,  Multiple.     (Pseudo-Tabes),       ...         76,  104,   105,  107 
Neuritis,  Retro-bulbar,       .         .         .        109,  iio,   189-199,  214,  215,  217 

Neuritis,  Retro-bulbar  Acute 19 1 

Neuritis,  Simple  of  Optic  Nerve,     .         .         .       102,  103,   104,   107,  215 

Neuro-Paralytic  ICeratitis, 24 

Nuclear  Paralysis, 36,  49 

Neuroses, .       143 

Neuroses,  Ocular, 174 

Nose,  Affections  of ,  16,  18,  170 


INDEX.  243 

Nose-bleed, j_q 

Nose  and  Teeth,  Nervous  Anastomoses  between  Eye  and,  .  180 

Nothnagel's  Memory  Centre, 120 

Nyctalopia, 217 

Nystagmus, 50,  53,  159,  2x9 


^CULAR  Affections  a  Cause  of  Functional  Nervous  Diseases, 

How  to  Determine,  ........       172 

Ocular  Affections  caused  by  Poisons,       .....        214-221 

Ocular  Affections   due  to   Poisonous    Substances   in    Food    and 

Drink, 221,  224 

Ocular  Affections  caused  by  Therapeutic  Agents,  .  ,       2co 

Ocular  Conditions  Attending  and  Following  Anaesthesia,       .        .      224 

Ocular  Neuroses, 174 

Ocular  Vertigo, ....       169 

Oedema  of  Conjunctiva, 24 

Oedema  of  Lids, 11,  12,  218 

Olivary  Body  (Superior),  Function  of, 40 

Ophthalmic  Migraine 167 

Ophthalmic  Vein,  Phlebitis  of, 83 

Ophthalmoscopic  Appearance  of  Fundus, 80 

Opium, 199 

Opium  Poisoning 76 

Optic  Chiasm, no 

Optic  Ganglia,  Functions  of, 112 

Optic  Nerve,  Affections  of, 84,  98,  103 

Optic  Nerve,  Atrophy  of,  .  104,  105,  106,  107,  195,  196,  215 

Optic  Nerve,  Course  and  Termination  of  Fibres  of,      .      no,  in,  ii.-? 

Optic  Nerve,  Inflammation  of, 102,  103 

Optic  Radiation  of  Gratiolet, iii,  119,  120 

Optic  Thalmus,  Affections  of, 40,  68,  III 

Optic  Tract, no,  m,  118,  119 

Ophthalmoplegia, 33.  37.  42 

Orbicularis,  Spasm  of, i6,  153 

Orbit,  Caries  of, 21 

Orbit,  Suppuration  within, 12,     22 

Orbital  Artery,  Aneurism  of 22 


pACHY-MENINGlTIS-Hemorrhagica lor 

Paragraphia, 126 


244  INDEX. 

Paralexia, 125 

Paralysis  Agitans *5.     '7 

Paralysis,  Alternating, 36.     37 

Paralysis,  Associate, 38,     39 

Paralysis,  Basilar, 35 

Paralysis,  Conjugate, 37.  3^.  41 

Paralysis,  Cortical 36,  41.  42,  43 

Paralysis,  Dissociate, 43 

Paralysis,  Hysterical 158 

Paralysis  of  Insane,   .  .      68,  71,  73,  75,  77,  104,  105,  114,  125 

Paralysis,  Intracerebral 36 

Paralysis  of  Levator  of  Upper  Lid,  .        .  .        .  17 

Paralysis,  Nuclear, 36,  37.    41 

Paralysis,  Nuclear,  Pathology  of, 48,    49 

Paralysis,  Peripheral, 34 

Paralysis,   Post- Diphtheritic, 79 

Paralysis,  Progressive,       .         .         .       68,  71,  73,  75,  77,  104,  105,  125 
Paralytic  Aflfections  of  External  Ocular  Muscles,    31,  44.  45.  47. 

158,  219,  222 

Parenchymatous  Keratitis, 23 

Paresis,  General,  47,  68,  71,  73,  75,  77,  104,  105,  114,  125 

Paretic  Mydriasis, 65,  67 

Paretic  Myosis, 74.  105 

Parrot's  Sign, 65 

Perimeter,  Diagram  of, 116 

Peripheral  Paralysis,  . 34 

Pernicious  Anaemia 88,  92 

Phlyctenular  Conjunctivitis, 18,  19 

Phlebitis  of  Ophthalmic  Vein 83 

Pigmentation  of  Skin  of  Lids, 11 

Phosphorus,  Poisoning  by 87 

Poisoning,  Fungus, 221,  222 

Poisoning  by  Lead 87,  194,  199 

Poisoning,  Ptomaine, 222,  223 

Poisoning  by  Opium, 76 

Poisons  a  Cause  of  Ocular  Affections, 214-224 

Poisons,  Disorders  of  Vision  due  to,         ...  .        214-218 

Polyopia,  Monocular, 217 

Pons,  Affections  of, 36,  37.  38,  39.  40.  42,  74 

Post-Diphtheritic  Paralysis, 76 

Posterior  Spinal  Sclerosis, M.  iS 


INDEX.  245 

Pregnancy,  Retinitis  of, 92,  124 

Progressive  Paralysis,         ...        68,  71,  73,  75,  77,  104,  105,  125 

Protrusion  of  Eye-ball, 22,  219 

Ptomaine  Poisoning, 222,  223 

Ptosis, 16,  211,  221 

Ptosis,   Hysterical, 17^  158 

Ptosis,  Morning, 16 

Ptosis,  Sympathetic, 15 

Puerperal  Fever, 83 

Pulsation  of  Retinal  Arteries, 85 

Pulvinar,     .         , m,  ng 

Pupil,  Behavior  of, 58 

Pupil,  Behavior  during  Anaesthesia, 224 

Pupil,  Behavior  in  Epilepsy, 153 

Pupil,  Behavior  in  Hysteria, 159 

Pupillary  Phenomena  due  to   Drugs, 210,  211 

Pyaemia, 83,     87 


DACHITIS. 54,  55 

Railway  Spine, 103 

Reflex  Action,  Mechanism  of  Production,      .         .         .174,  175,  176 

Reflex  Action,  Pathological, 177,  178 

Reflex,  Light, ,        .        .        .          61,  69,  118 

Reflex  Neuroses,  Local  Ocular, 165 

Reflex,  Skin, 63,  66,  74 

Reflexes,  Aural  Ocular, 185 

Reflexes,  Dental  Ocular,    ...,...,       180,  185 

Reflexes,  Nasal  Ocular 180,  185 

Reflexes,  Pathological  Ocular, 180 

Reflexes,  Physiological  Ocular,  Examples  of,        .        .        .         .179 

Refraction,  Errors  of,  A  Cause  of  Headache,         .       166,  167,  168,  169 

Refraction,  Errors  of,  A  Cause  of  Neurasthenia,  .        .        .       156,  171 

Retina,  Affections  of, 84 

Retina,  Hyperaemia  of, 85 

Retinal  Artery,  Central,  Embolism  of, 86 

Retinal  Arteries,  Hemorrhage  from,         ....        86,  2:0,  222 

Retinal  Arteries,  Pulsation  of, 85 

Retinitis, 8S,  104 

Retinitis  Albuminurica, 90 

Retinitis  Diabetica, 99 

Retinitis,  Gouty, 98 


246  INDEX. 

Retinitis  Leukaemica 97 

Retinitis,  Nephritic, 89,  90 

Retinitis  of  Pregnancy 92,  124 

Retinitis  Sjrphilitica,                  96 

Retro-bulbar  Neuritis,                .                109,  no.  1S9-199,  214,  215,  217 

Rheumatism, 23,  24,  47,  57,  191. 

Rheumatic  Iritis, 57 

Romberg's  Smyptom, 156 


CARCOMA, 56 

Scarlet  Fever, 104 

Sclera.  Tuberculosis  of, 23 

Scleritis, 23 

Sclerosis,  Multiple, 47.  52,  78,  79,  104,  105 

Sclerosis,  Post  Spinal, 14,     15 

Scotoma,  Scintillating, 167 

Scrofula, 12,  rS,  23,  83 

Sensation,  False  Localization  of. "•  25,  106 

Sensation,  Disorders  of  in  Hysteria, 159 

Septicaemia 87 

Sequence  of  Hemorrhages, loi 

Simulated  Blindness,  Detection  of, 160-162 

Skin,  Burns  of 87,     88 

Skin  Reflex, 63,  66,     74 

Skull,  Fracture  of, 103 

Snake  Bites 87 

Sneezing, 170 

Soul  Blindness, 124,  125 

Spasm  of  Accommodation, 158 

Spasm,  Conjugate  of  Eye  Muscles, 38,  42,  49 

Spasm  of  External  Ocular  Muscles, 49-53 

Spasm  of  Levator  of  Upper  Lid, 14 

Spasm  of  Mueller's  Muscle, 14 

Spasm  of  Orbicularis, 16,  153 

Spasm,  Vaso-motor,  a  Cause  of  Epilepsy, 150 

Spastic  Mydriasis 64,  66,  67 

Spastic  Myosis, 74 

Spinal  Congestion 66 

Spinal  Cord,  Disease  of, 75.     76 

Spinal  Cord,  Tumor  of, loi 

Spinal  Irritation 66 


INDEX.  247 

Spinal   Meningitis, 66 

Spine,  Concussion  of, 103 

Stellwag's  Sign, 14 

Strabismus, 50 

Stramonium, 199 

Sulphur  Chloride 199 

Swelling  of  Lids,        .         , 211,  219 

Sympathetic,  Influence  of  upon  Tension  of  Eye,           .        ,        .  184 

Sympathetic  Ptosis, 14 

Syphilis,     .         21,  23,  44,  46,  55,  56,  71,  79,  82,  86,  89,  96,  103, 

118,  119,  194 

Syphilis,  Inherited, 24,  96,  147 

Syphilitic  Coma, 76 

Syphilitic  Iritis, .        .  55,  56 

Syphilitic  Retinitis, 96 

TRADES,  (Locomotor  Ataxia),  11,  14,  17,  25,  44,  45,  46,  66,  71, 
^  ■  73,  75.  76,  77,  104,  105,  106,  112,  198 

Tabes,  Pseudo,  (Multiple  Neuritis),         ...        76,  104,  105,  107 

Tape-worm, 185 

Tea 199 

Teeth,  Disorders .  of, 16,  170 

Teeth  and  Eye,  Nervous  Anastomoses  between,     ....       180 

Thalamus,  Optic, m 

Thalamus  Opticus,  Affections  of, 40,     68 

Therapeutic  Agents  a  Cause  of  Opular  Affections 200 

Tobacco  Amblyopia, 191-198 

Toxic  Amblyopia, 107,  189-199 

Tracts,  Optic, no,  m,  118,  119 

Transient  Amblyopia, 122 

Tremor  of  Lids, ,        •        •        i5,  211 

Trichinosis, •        .        •         12,     79 

Tubercula  Quadrigemina, 40 

Tubercular  Meningitis,        .  40,  50,  7o>  74,  7^,  83,  loi,  102,  119 

Tuberculosis,       .         .         .  21,  23,  83 

Tuberculosis  of  Conjunctiva,  20 

Tuberculosis  of  Iris, 5^ 

Tuberculosis  of  Lids '3 

Tuberculosis  of  Sclera, 23 

Tumor  of   Brain,         .....          70,  99,   100,  loi,  102,  105 
Tumor  of  Spinal  Cord loi 


248  INDEX. 

Typhoid  Conditions, 24,  83,  104 

I  TRAEMIA, 71.  76,  123,   124 

Urticaria, 66 

Uterine  Disease, H-  79.  185 

WASO-MOTOR  Disturbances  in  Hysteria, 160 

Vaso-motor  Spasm  a  Cause  of  Epilei'sy,  .150 

Ventricle,  Hypertrophy  of  Left, 83 

Ventricle,  Third,  Accumulation  of  Fluid  in,  .118 

Vertigo,  Ocular, 169 

Vision,  Binocular,  Requisites  for 145,  146 

Vision,  Colored, 20S,  209 

Vision,  Disorders  of  due  to  Drugs,  .....        200-210 

Vision,  Disorders  of  due  to  Poisons,        .         .         .         ,         ,        214-218 
Vision,  Methods  of  Estimating  Acuity  of,      .  .  108,  109 

Visual  Aurae  in  Epilepsy,         .......       149,  150 

Visual  Centres,  ....       113,   119,   120,  121,  122,  123,  126 

Visual  Centre,  Affections  of, 38,  42,  167 

Visual  Disorders,  Cortical,  38,  42,  113,  119.  120,  121,  122,   123,  126,  127 

Visual  Field  for  Color, 115 

Visual  Field  in  Hysteria, 162,  165 

Visual  Field,  Method  of  Examination,  .  116,  117 

Visual  Fields,  Normal  Boundaries  of 114 

Visual  Hallucinations,  .         .        118,  119,  124,  208,  215,  222 

Vitreous,  Opacities  of 220 

Von  Graefe's  Sign, 15 

\X7ERNICKE'S  Sign,  (Hemianopic  Pupillary  Inaction  1,  .         68 

Winking,  Diminished  Frequency  of, 14 

Winking,  Spasmodic 16 

Xerosis  of  Conjunctiva, .25 


QphthaTiTTC 


tPriee,  $1.00. 


Opei'atTons 


>%<'>. («V<'«.l%*»<,>»>/"«.»'»J"«. 


^s  Pvact^c^d  on  ^n^rpaTs'  ^y^s* 


By  Clarence  A.  Veasey,  A.  M.,  M.  D, 

Adjunct  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  ;  Chief  Clinical  Assistant  to  the  Oph- 

thalmological  Department  Jefferson  Medical  College  Hospital ;  Consulting 

Ophthalmologist,  Philadelphia  Lying-in  Charity,  etc. 


Fiftg-Six  lIlustratiOQS,  piaqy  of  tliem  Eqtirely  New  aqd  Prepared  Especially  for  tHis  work. 

THE  object  of  this  work  has  been  to  present  to  the  student  and 
practitioner  entering  the  field  of  operative  ophthalmology  a  re- 
liable guide  to  the  various  operations  that  can  be  practiced  on 
animals'  eyes,  to  enable  him  to  possess  a  greater  experience  and  a  lar- 
ger amount  of  confidence  in  himself  when  attempting  operative  work 
on  the  human  eye.  The  various  operations  are  taken  up  and  the  meth- 
ods and  technique  of 
performing  them  fully 
described  and  illustra- 
ted, so  that  one  may 
become  thoroughly  fa- 
miliar with  any  opera- 
tive procedure,  prac- 
ticing it  as  many  times 
as  he  chooses. 

So  far  as  can  be  as- 
certained this  is  the 
first  time  this  matter 
has  appeared  in  book 
form.    Heretofore,  the 


"Dr.  Veasey  in  the  compilation  of  this  book  has  filled  a  void 
in  ophthalmic  literature,  and  has  given  to  the  student  of  ophthal- 
mology an  aid  that  has  long  been  wanted. — Atlantic  Medical  Re- 
view, 

"' Ophthalmic  Operations'  is  so  full  of  practical  information 
so  concisely  stated,  that  every  practitioner,  as  well  as  student, 
should  possess  it." — Bi-Monthly  Bulletin  oj  the  University  College  of 
Medicine,  Richmond,  Va. 

"  *  *  *  *  The  reviewer  having  found  it  useful  among  his  own 
students,  cordially  recommends  W..'''— International  Med.  Magazine. 


"It  was  a  happy 
thought  which  inspir- 
ed Dr.  Veasey  to  pre- 
pare this  book." — The 
Medical  Bulletin. 


OPINIONS 
OF  THE  PRESS. 


"It  is  cheerfully 
recommended  for  the 
purpose  it  is  intend- 
ed to  fulfill."— /^/i/Va- 
dclphia  Polyclinic. 


"This  little  manual  has  a  distinct  place  in  ophthalmic  work. 
*  *  *  *  We  commend  it  to  the  teachers  of  Ophthalmology.''— CWo- 
rado  Medical  yournal. 

"There  is  certainly  room  for  a  book  of  this  kind  *  *  *  *  Dr. 
Veasey's  little  book  ought  to  have  a  wide  circulation." — Annals  cf 
Oph  thaltn  ology . 

"  We  believe  that  this  little  book  meets  a  real  need  of  both 
teacher  and  student." — The  Ophthalmic  Review. 

"  The  little  volume  fulfills  its  purpose." — Archives  of  Ophthal- 
mology. 


only  way  in  which  the 
information  contained  therein  could  be  obtained  was  through  personal 
instruction  or  through  some  operative  course  in  a  public  institution. 
This  little  work  is  intended  not  only  to  assist  those  who  are  able  to 
avail  themselves  of  such  courses  of  instructions,  but  also  those  who  are 
less  fortunate  in  being  remote  from  the  medical  centres  where  such 
courses  can  be  obtained. 


The  Edwards  &  Docker  Co., 

518=520  ninor  Street,    =      Philadelphia. 

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II  If" 


Op^T  rj  ^^"^^13^^  ■"**  '**/^  Ppaetieal  Application 
^J^^'^^^^y^^  X  to  t^^e  Study  of  Refraction. 

BY  HDWni^D  UnCKSON.   A.  M->   fi-  o. 
Professor  of  Diseases  of  the  Eye  In  the  Philadelphia  Polyclinic,  Surgeon  to  Wills'  Eye  Hospital,  Etc.,  Etc. 


Skiascopy  is  the  most  accurate  objective  method  of  measuring  re- 
fraction, and  the  one  with  which  it  is  easiest  to  obtain  a  practical  work- 
ing acquaintance.  This  book  gives  the  clearest,  most  complete,  and 
most  practical  account  of  it  yet  published. 

"Bears  the  stamp  of  personal  experience  and  original  observation,  and  cannot  be  too  highly  rec- 
ommended to  >  ver^  oculist  and  physician  desirous  of  btcoming  thoroughly  familiar  with  the  theory 
and  practice  ot  skiascopic  examination."— 7(»»<r«a/tf/"M*  American  Medical  Association. 

"All  Ophthalmologist"  will  welcome  Dr.  Jackson's  little  manual.  It  is  an  authoritative  and  excel- 
lent exposition  of  ihe  subject  with  which  it  deals." — Medical  News. 

"  This  is  an  excellent  book.  No  ophthalmologist  can  consider  himself  abreast  of  the  times  unless 
he  understands  skiascopy,  and  a  better  text  book  on  the  subject  cannot  be  found." — N.  V.  Med.  J^ourna/. 

"  This  little  book  gives  a  very  complete  and  serviceable  presentation  of  the  theorj^  of  the  shadow- 
test,  and  its  practical  applications.  To  many  it  will  seem  too  diffujie  ;  but,  in  reality,  it  contains  but  lit- 
tle superfluous  matter  at  least  for  those  who  have  but  an  imperfect  previous  knowledge  of  this  useful 
method  of  examination  Even  one  who  has  somewhat  extensive  experience  iu  the  latter  will  find  in- 
formation and  mauv  useful  hints." — Archives  of  Ophtkahnology. 

"  The  work  as  a  whole  is  very  ci  editable  ;  and  the  practitioner  who  takes  the  trouble  to  master  its 
contents  will  know  all  that  can  be  said  of  this  very  excellent,  speedy  and  satisfactory  mode  of  deter- 
mining the  nature  and  degree  of  iKJth  common  and  uncommon  errors  of  refraction."—  The  Lancet. 

"Altogether  this  little  book  of  109  pases  is  one  so  full  of  practical  information  that  it  should  be 
studied  by  every  one  who  is  not  a  thorough  master  of  the  subject  treated."   -Ophthalmic  Record. 

VONAa  100  Pages  with  21  Illustrations. 

(y  BOUND    IN    CLOTH.     ^I.OO. 

The  £  Examination  of  the  Eye 

By  J.   HE^BEHT  CLtniBOf^NB.   JP.,   M-  D-. 

Adjunct  Professor  of  Ophthalmology  in  the  N.  Y.  Polyclinic  ;    Instructor  in  Ophthalmology.  College  ot 

Physicians  and  Surgeons,  N.  Y.;  Assistant  Surgeon  to  the  New  Amsterdam  Eye  and  Ear 

Hospital;  Author  of  "  Theory  and  Practice  of  Ophthalmoscope." 


"  Without  making  any  claims  for  originality,  except  in  his  treatment  of  the  subject,  which  is  simple 
and  attractive,  the  author  has  presented  a  book  on  refractive  errors  and  their  correction  which  is  ad- 
mirably adapted  to  the  use  of  students  and  beginners.  The  book  contains  in  addition  chapters  on  the 
properties  of  lenses,  vis'on  and  mydriatics.  It  is  neatly  gotten  up  and  appropriately  illu.strated. "—//»- 
maopathic  Eye,  Ear  and  Throat  yournal,  N.  Y. 

"  Contains  the  facts  necessary  for  the  examination  of  the  eye  as  pertaining  to  refraction  expressed 
in  a  simple,  clear  and  attractive  manner — a  fit  companion  for  the  author's  ptevious  work  on  the  oph- 
thalmo^cope.     The  type  and  binding  are  also  excellent." — The  Canadian  Medical  Review. 

"This  book  consists  of  a  number  of  lectures  or  lessons  on  the  subject  of  fitting  glasses  delivered  to 
the  graduatini;  classes  of  the  College  of  Physicians  and  Surgeons,  New  York.  The  method  of  properly 
adjusting  glasses  in  cases  of  hvpermetropia,  myopia,  astigmatism  and  presbyopia  is  described  in  an  at- 
tractive way,  and  is  made  so  clear  that  the  book  undoubtedly  will  prove  a  valuable  aid  to  students  and 
beginners.  The  chapter  on  Presbyopia  is  unusually  full,  and  contains  the  substance  of  all  that  has  gone 
before.  The  important  subject  of  Mydriatics  is  di-scussed  in  the  last  chapter  ;  forni'ilse  are  given  and 
suggestions  made  as  to  the  cases  in  which  they  are  indicated."— /'/crf/Vrt/  and  Surgical  Journal,  St.  Louis. 


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A  JVlonthl>  Journal  Devoted  to 

The  Natural  Sciences 

in  their  widest  sense. 


Jxatupalist 


THE  AMERICAN  NATURALIST  differs 
from  most  other  Journals  iti  the  extent 
and  efficiency  ot  its  editorial  corps, 
which  embraces  eleven  :nen,  mostly  profes- 
sors in  well-known  Universities  in  Maine, 
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phia, Baltimore  and  Washington  ;  and  Lin- 
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secures  competent  criticism  on  the  subject 
matter,  as  well  as  breadth  of  scope.  In  this 
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N.4TURAL1ST — the  presentation  to  the  public 
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Ithaca,  N.  Y. 

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The  University  of  Nebraska,  Lincoln,  Neb. 

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ERWIN  F.  SMITH, 

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College  of  New  Hampshire,  Durham,  N.  H. 

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Johns  Hopkins  University,  Baltimore,  Md. 

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Princeton,  N.J. 

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